






I 







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THE GEORGE BLUMER 

EDITION OF 

BILLINGS-FORCHHEIMER’S 

THERAPEUSIS OF INTERNAL DISEASES 


VOLUME I 




THE GEORGE BLUMER 

EDITION OF 

BILLINGS-FORCHHEIMER’S 
THERAPEUSIS 
OF INTERNAL DISEASES 

CARE AND MANAGEMENT OF MALADIES 
AND AILMENTS OTHER THAN SURGICAL 





VOLUME I 


D. APPLETON AND COMPANY 

NEW YORK 1924 LONDON 


“RMi'oi 


copyright, 1913 , 1914 , 1917 , 1924 , by 
D. APPLETON AND COMPANY 



* v * 




PRINTED IN THE UNITED STATES OF AMERICA 


NOV 1? 74 


©Cl A 80S7C7 

1 


''We 



EDITED BY 


GEORGE BLUMER, M.A. (Yale), M.D. 

DAVID P, SMITH CLINICAL PROFESSOR OF MEDICINE, YALE UNIVERSITY SCHOOL OF MEDICINE, 
ATTENDING PHYSICIAN TO THE NEW HAVEN HOSPITAL 


FORMER EDITORS 


FREDERICK FORCHHEIMER, Sc.D. (Hary.), M.D. 

FORMERLY PROFESSOR OF MEDICINE, MEDICAL DEPARTMENT, UNIVERSITY OF CINCINNATI 
(OHIO-MIAMI MEDICAL COLLEGE), PHYSICIAN TO CINCINNATI HOSPITAL 


FRANK BILLINGS, Sc.D. (Harv.), M.D. 

PROFESSOR OF MEDICINE, UNIVERSITY OF CHICAGO AND RUSH MEDICAL COLLEGE, CHICAGO 


ERNEST E. IRONS, Ph.D., M.D. 

CLINICAL PROFESSOR OF MEDICINE, RUSH MEDICAL COLLEGE, CHICAGO 
























PREFACE TO THE FOURTH EDITION 

The Editor who assumes to revise a work planned by such masters 
of medicine as Frederick Forchheimer and Frank Billings has no enviable 
task. Nevertheless, he is aided by the factor of time, for in no branch 
of applied science is progress more rapid than it is in the practice of 
medicine. In the years which have elapsed since the last revision of this 
work, numerous discoveries have been made; and this statement is particu¬ 
larly true when one deals with the subject of applied therapeutics. In 
addition, numerous discoveries have been made bearing upon the classifica¬ 
tion of disease, on its etiology, on its pathology, and it has been the aim 
of the Editor to incorporate these into the present edition. 

The study of disease from the functional standpoint has progressed 
so rapidly, and this study has thrown so much light into hitherto dark 
corners that a consideration of remedial agencies from this view of 
pathology is an urgent necessity in present day therapeutics. 

The reader will find in the present edition a rearrangement of the 
infectious diseases, necessitated by added knowledge regarding etiology. 
A section on therapeutic technic has been added to the second volume, 
in order to emphasize the more technical aspects—paracentesis, vene¬ 
section, transfusion, etc.—and the general principles underlying the ad¬ 
ministration of medicine by various routes. 

The section on intoxications has been greatly expanded, and an attempt 
has been made to arrange it so that the various aspects of intoxication are 
discussed in the form in which they present themselves to the general 
practitioner. The sections dealing with diseases due to dietary deficiencies 
and anaphylaxis have been entirely revised and rearranged. 

An entirely new section on occupational diseases, the importance of 
which has been emphasized by the numerous State Compensation Laws, 
has been written. The section on the diseases of the circulatory organs 
has been rearranged and almost entirely rewritten. New sections dealing 
with the treatment of the common affections of the eye, ear, and skin 
have been introduced, and also chapters dealing with such minor surgical 
and gynecological infections as can be handled satisfactorily by the general 

practitioner. . 

The importance of a thorough knowledge of applied therapeutics is ot 
such positive moment to the man in practice that the revision of this 
work becomes of importance to the entire profession. Under the able 
editorial supervision of Frederick Forchheimer and Frank Billings, this 
work achieved a national acceptance and international recognition that has 
never been given to any other American work covering the same field. 

vii 


viii PREFACE TO THE FOURTH EDITION 

In order to maintain the position of this work, the Editor has used his 
best endeavor to select authors for the new sections who are masters in 
their chosen fields, and, where the articles of previous authors have been 
rewritten by some one other than the original, the same care has been 
exercised. 


George Blumer 


PREFACE TO THE FIRST EDITION 


This work was undertaken because it seemed that a presentation 
in extenso of the therapeusis of internal diseases might he valuable to 
all those engaged in the practice of medicine. 

I venture to say that the subject of the treatment of internal diseases 
is fast becoming, if it has not already become, one of the most impor¬ 
tant subjects we have to deal with, either as practitioners or teachers. 
The reason for this is obvious. Not very long ago the basis of all therapy 
was empiricism, and empiricism only. Then followed a period in which 
metaphysical reasoning replaced empiricism, giving rise to the develop¬ 
ment of schools, and not infrequently of medical sects, some of which 
still survive even in this period of scientific enlightenment. It may be 
added that even now new sects are arising, and possibly will continue to 
arise as long as human credulity survives. 

Following this metaphysical period we meet with a most interesting 
therapeutical manifestation, that of medical nihilism. That great clini¬ 
cian, Skoda, for instance, believed so little in drugs that he treated all 
his typhoid fever patients by giving them small doses of a weak solution 
of alum. But, on the other hand, he was the first to place auscultation 
and percussion upon a physical basis. For him, then, there was no science 
of therapeusis, although there was science in percussion and auscultation. 
The nihilistic tendency still has adherents, although their number is small 
and constantly growing smaller. 

Comparatively recently laboratories began to play a very important 
role. Physiology, pathology, chemistry, microscopy, and physics as 
applied to medicine were being developed, and theoretical therapeutic 
problems were being solved by laboratory methods, which, in turn, of 
themselves have become a fetish. 

Moreover, there was more careful and accurate observation of disease. 
But the most, conspicuous and important contribution to our therapeutic 
knowledge in this connection consisted in the acceptance of physiological 
effects of drugs and their determination. With this to go upon medical 
therapeusis received a great and fruitful impetus. It may be safely said 
that this was the beginning of scientific medical therapeusis; for the 
first time it was possible to come to a therapeutic conclusion which was 
scientific in a measure: the result of observation plus reasoning. 

If we now come to our present day we see a remarkable state ot affairs. 
Not only have the therapeutics ef to-day been developed beyond anything 

ix 


X 


PREFACE TO THE FIRST EDITION 


that could have been hoped for twenty-five years ago, hut vistas are being 
opened which promise advances hoped for only in some dim future state. 
And yet, if we reflect, the time had come for great and radical advances 
in this line. The branches of science already mentioned upon which 
treatment is based had developed to a degree that seemed incredible, and 
each advance was eagerly seized upon by those who were prepared and 
ready to apply this development. 

Therapeutics, therefore, is beginning to take a place with the other 
branches of medicine, in as far as its scientific status is concerned. That 
therapeutics will ever be a pure science seems, at present, out of the ques¬ 
tion. But the fact that it is what it has developed to be leads us to 
believe that it is as yet in its infancy. 

The great advances that can be recorded in our period are found in 
prophylaxis and causal or specific therapy. 

In prophylaxis, especially in infectious diseases, results are obtained 
which a short time ago would have been considered impossible. The 
greatest enthusiast would have deemed it incredible, for instance, that 
the day would ever come when Havana would quarantine against Key 
West in yellow fever. Many other instances could be cited in which 
modern prophylaxis has prevented the spread of disease and the develop¬ 
ment of epidemics. Indeed, this is now so common that very little ado 
is made of it. Much more remarkable, however, is the rendering sani¬ 
tary large tracts of land which were uninhabitable before, thus giving 
more and better chances for life and health to more human beings. 

As wonderful as this seems, the greatest advance made in therapeusis 
has been in causal therapy. We are no longer solely guided in the use 
of drugs by their physiological effects, but demand effects upon patho¬ 
logical states and conditions, in this way coming nearer the cause of 
things and frequently removing it. The treatment of specific causes by 
specific methods of treatment is especially notable at the present time. 
Formerly there were two specifics: mercury and quinia. At present 
there is a large number in infectious diseases, in the form of vaccination 
with virus from animals less susceptible than man, by vaccinating with 
small numbers of bacteria from violent cultures, by injecting dead 
bacilli and bacterial products and sera. Relatively still in their infancy, 
these modes of treatment have already changed the therapeusis of infec¬ 
tious diseases. 

Furthermore, there has taken place a revival in the use of physical 
measures, which have proved themselves very valuable in the light thrown 
upon them by modern modes of investigation. I refer here to hydro¬ 
therapy, balneology, massage and gymnastics, mechanotherapy, electro¬ 
therapy, light therapy, Roentgen ray therapy. Nutrition and dietetics 
have been put upon a scientific basis, and psychotherapy is being applied 
in a rational way for definite purposes. One of the recent additions to 


PREFACE TO THE FIRST EDITION 


xi 


our knowledge, and one which promises much for therapeusis, is physical 
chemistry. By adding to this list of subjects toxicology, organotherapy, 
and climatology we have an enumeration of the means applied to the 
treatment of disease, except of that due to direct medication. If we 
except this, which it seemed to me required no especial mention or space, 
as it is discussed and described throughout the book, we have subjects 
that have a broad general bearing, so that I have grouped them together 
under the heading of General Therapy and given the whole of the first 
volume to their discussion. As far as I know, this was first attempted 
in the “Handbuch der allgemeinen Therapie,” edited by H. von Ziemssen 
in 1883. It would seem to me that the grouping of these subjects is 
invaluable as forming a foundation upon which the whole of therapeusis 
may be built up. Not alone is this the case, but they serve to bind the 
various subjects together. The practical value of this division lies in 
the fact that the general therapeutic measures are fully described and 
reference can be made to them. 

Having then made one division of the whole subject, we follow the 
Germans and make a second, that of special therapy, which includes the 
treatment of all diseases which are classified as belonging to internal 
medicine. Here it is not only the treatment of a special disease, but also 
the special treatment of a special patient, which makes the subject one 
beset with great difficulties as well as of transcendent interest. As a re¬ 
sult of the complexity of the subject it will be readily seen that there is 
no branch of medicine which may not have some bearing on special treat¬ 
ment; this applies to anatomy, physiology, physics, chemistry, pathology, 
symptomatology, pharmacology, to mention only the most important ones. 
Moreover, the mutual relations of internal medicine to other departments, 
such as surgery and the various specialties, must be considered. In these 
days of multiplication of specialties internal medicine itself may be over¬ 
looked, so that only a part of the condition and not the whole is treated. 
The fact that a prescription is the last act in a long process of reasoning 
should always be borne in mind. 

The prescription should not be written until everything which bears 
upon the condition of the patient has been considered. It is necessary to 
make a diagnosis which must include pathology and pathogenesis, this 
especially for causal treatment. The symptomatology must be carefully 
investigated, as, in many instances, the relief of symptoms is all that can 
be done or all that should be done. The therapeutic measures to be taken 
should then be determined; if drugs, those that fulfill the indications 
should be chosen. In every case the individual characteristics of the 
patient should be studied. When all this has been done, the patient is 
ready for his prescription. 

It is in this spirit that the various subjects comprising the work have 
been treated by the contributors. Everything that has bearing upon 


PREFACE TO THE FIRST EDITION 


xii 

therapy is considered, and, as the subjects differ so much, it will readily 
be seen that uniformity could not be attained. Under all circumstances 
the primary object is to illuminate the subject of treatment and to give 
all that is known or worth knowing, and the work is primarily written 
for all those who wish to be informed of the details of treatment of dis¬ 
ease, even the smallest ones. 

Prescriptions are given in the text when found necessary; first, on 
account of showing how the drug is best administered; secondly, the 
quantity of drug to be given and at what intervals. The days of formulae 
are not over, and all of us, it must be confessed, like to employ a formula 
which has been recommended by a competent observer. All doses of 
drugs, as well as all prescriptions, are given in apothecary’s weight and 
in the metric system. 

The authors who have honored me by writing were chosen because 
I considered them thoroughly equipped and best able to write upon the 
subjects assigned to them. Their names and their reputations are a 
guarantee of the quality of their work. 

I wish to express my especial thanks to Drs. William Wherry and 
Joseph C. Collins for assistance given in the arrangement of these 
subjects. 


E. Forchheimer 


LIST OF CONTRIBUTORS 


Maude E. Abbott, B.A., M.D., L.R. 
C.P., L.R.C.S. (Edin., Glasg.) 

Arthur N. Ailing, A.B., M.D. 

John F. Anderson, M.D. 

John Auer, B.S., M.D. 

Lewellys F. Barker, M.D., LL.D. 

William Nathaniel Berkeley, A.B., 
B.Ph., M.D. 

Henry Wald Bettman, B.L., M.D. 

Frank Billings, M.D., Sc.D. 

Ernest S. Bishop, M.D., F.A.C.P. 

Kenneth D. Blackfan, M.D. 

Francis G. Blake, A.B., M.A., M.D. 

George Blumer, M.A., M.D. 

Ernst P. Boas, B.S., M.A., M.D. 

John W. S. Brady, A.B., M.D. 

Harlow Brooks, M.D. 

C. S. Butler, A.B., M.D., U. S. 
Navy. 

Joseph A. Capps, A.M., M.D. 

Anton Julius Carlson, A.M., Ph.D., 
M.D., LL.D. 

Russell L. Cecil, A.B., M.D. 

Henry T. Chickering, A.B., M.D. 

Henry A. Christian, A.M., M.D., 
LL.D. 

Rufus Cole, M.D. 

xiii 


Warren Coleman, A.B., A.M., M.D. 

Joseph Collins, M.D. 

A. N. Creadick, M.D., F.A.C.S. 

S. T. Darling, M.D., D.Sc. 

Wilburt C. Davison, B.Sc., M.A. 
(Oxon.), M.D. 

W. H. Deaderick, M.D., F.A.C.P. 

Archibald J. Dickson, M.D. 

Ernest C. Dickson, B.A., M.D, 

Joseph C. Doane, M.D. 

A. R. Dochez, A.B., M.D. 

George Dock, A.M., M.D., Sc.D. 

Alvah H. Doty, M.D. 

George Draper, A.B., M.D. 

Arthur B. Duel, M.D., F.A.C.S. 

William Core Duffy, A.B., M.D., 
F.A.C.S. 

Charles Warren Duval, M.A., M.D. 

Henry L. Eisner, M.D. 

Charles Phillips Emerson, A.B., 
M.D. 

Martin H. Fischer, M.D. 

Otto H. Foerster, M.D. 

Frederick Forchheimer, M.D., Sc.D. 

William Webber Ford, A.B., M.D., 
D.P.H. 

Thomas B. Futcher, M.B. 


PREFACE TO THE FIRST EDITION 


xii 

therapy is considered, and, as the subjects differ so much, it will readily 
be seen that uniformity could not be attained. Under all circumstances 
the primary object is to illuminate the subject of treatment and to give 
all that is known or worth knowing, and the work is primarily written 
for all those who wish to be informed of the details of treatment of dis¬ 
ease, even the smallest ones. 

Prescriptions are given in the text when found necessary; first, on 
account of showing how the drug is best administered; secondly, the 
quantity of drug to be given and at what intervals. The days of formulae 
are not over, and all of us, it must be confessed, like to employ a formula 
which has been recommended by a competent observer. All doses of 
drugs, as well as all prescriptions, are given in apothecary’s weight and 
in the metric system. 

The authors who have honored me by writing were chosen because 
I considered them thoroughly equipped and best able to write upon the 
subjects assigned to them. Their names and their reputations are a 
guarantee of the quality of their work. 

I wish to express my especial thanks to Drs. William Wherry and 
Joseph C. Collins for assistance given in the arrangement of these 
subjects. 


F. Fokchheimer 


LIST OF CONTRIBUTORS 


Maude E. Abbott, B.A., M.D., L.R. 
C.P., L.R.C.S. (Edin., Glasg.) 

Arthur N. Ailing, A.B., M.D. 

John F. Anderson, M.D. 

John Auer, B.S., M.D. 

Lewellys F. Barker, M.D., LL.D. 

William Nathaniel Berkeley, A.B., 
B.Ph., M.D. 

Henry Wald Bettman, B.L., M.D. 

Frank Billings, M.D., Sc.D. 

Ernest S. Bishop, M.D., F.A.C.P. 

Kenneth D. Blackfan, M.D. 

Francis G. Blake, A.B., M.A., M.D. 

George Blumer, M.A., M.D. 

Ernst P. Boas, B.S., M.A., M.D. 

John W. S. Brady, A.B., M.D. 

Harlow Brooks, M.D. 

C. S. Butler, A.B., M.D., U. S. 
Navy. 

Joseph A. Capps, A.M., M.D. 

Anton Julius Carlson, A.M., Ph.D., 
M.D., LL.D. 

Russell L. Cecil, A.B., M.D. 

Henry T. Chickering, A.B., M.D. 

Henry A. Christian, A.M., M.D., 
LL.D. 

Rufus Cole, M.D. 

xiii 


Warren Coleman, A.B., A.M., M.D. 

Joseph Collins, M.D. 

A. N. Creadick, M.D., F.A.C.S. 

S. T. Darling, M.D., D.Sc. 

Wilburt C. Davison, B.Sc., M.A. 
(Oxon.), M.D. 

W. H. Deaderick, M.D., F.A.C.P. 

Archibald J. Dickson, M.D. 

Ernest C. Dickson, B.A., M.D. 

Joseph C. Doane, M.D. 

A. R. Dochez, A.B., M.D. 

George Dock, A.M., M.D., Sc.D. 

Alvah H. Doty, M.D. 

George Draper, A.B., M.D. 

Arthur B. Duel, M.D., F.A.C.S. 

William Core Duffy, A.B., M.D., 
F.A.C.S. 

Charles Warren Duval, M.A., M.D. 

Henry L. Eisner, M.D. 

Charles Phillips Emerson, A.B., 
M.D. 

Martin H. Fischer, M.D. 

Otto H. Foerster, M.D. 

Frederick Forchheimer, M.D., Sc.D. 

William Webber Ford, A.B., M.D., 
D.P.H. 

Thomas B. Futcher, M.B. 


XIV 


LIST OF CONTRIBUTORS 


A. Galambos, M.D. 

Henry J. Gerstenberger, M.D. 

Harry L. Gilchrist, M.D., F.A.C.S. 

Samuel J. Goldberg, M.D. 

Malcolm Goodridge, M.D. 

Alfred C. Gordon, M.D. 

L. Whittington Gorham, M.D. 

Charles Lyman Greene, M.D. 

J. P. Crozer Griffith, A.B., M.D., 
Ph.D. 

Julius Grinker, M.D. 

Erwin G. Gross, B.S., M.S., Ph.D. 

John T. Halsey, M.D. 

Louis Hamm an, M.D. 

Clinton B. Hawn, M.D. 

Henry H. Hazen, A.B., M.D. 

William Vincent Healey, A.B., 

M.D. 

N. Sproat Heaney, M.D. 

Yandell Henderson, Ph.D. 

James B. Herrick, A.B., A.M., 
M.D. 

William F. Hewitt, B.Sc., M.D. 

Arthur L. Holland, M.D. 

C. P. Howard, A.B., M.D., C.M. 

Hubert S. Howe, A.M., M.D. 

Guy L. Hunner, A.M., M.D. 

Ernest E. Irons, Ph.D., M.D. 

Chevalier Jackson, M.Sc., M.D., 
F.A.C.S. 

Henry Jackson, Jr., M.D. 


Howard Sheffield Jeck, Ph.B., M.D., 
F.A.C.S. 

Smith Ely Jelliffe, A.M., M.D., 

Ph.D. 

Charles Godwin Jennings, M.D. 

Jacob Kaufmann, M.D. 

Arthur I. Kendall, Ph.D., D.P.H. 

Lloyd Ketron, A.B., M.D. 

Edward L. Keyes, M.D., Ph.D. 

Herbert Maxon King, M.D. 

Benjamin Kramer, M.S., M.D. 

C. Guy Lane, A.B., M.D. 

A. J. Lanza, M.D. 

Roger I. Lee, A.B., M.D. 

Isaac Ivan Lemann, M.D. 

Emanuel Libman, M.D. 

Edwin A. Locke, Ph.B., A.M., 
M.D. 

George M. Mackenzie, A.B., M.D. 

William J. M. A. Maloney, M.D., 
Ch.B., LL.D., F.R.S. (Edin.) 

David Marine, A.M., M.D. 

C. F. Martin, B.A., M.D., C.M. 

Thomas McCrae, M.D., F.R.C.P. 
(London.) 

Alexander McPhedran, M.D., LL.D. 

Wm. Fletcher McPhedran, B.A., 
M.D. 

Frank S. Meara, A.B., M.D., Ph.D. 

Joseph L. Miller, B.S., M.D. 

A. Graeme Mitchell, M.D. 

Herbert C. Moffitt, B.S., M.D. 
LL.D., Sc.D. 


LIST OF CONTRIBUTORS 


William L. Moss, B.S., M.D. 

Hideyo Noguchi, M.D., M.S. (U. 
of P.), PH.D. (Jap. Govt.), Sc.D. 

Thomas Ordway, M.D. 

Alfred Townsend Osgood, M.D. 

Reuben Ottenberg, A.M., M.D. 

Walter Walker Palmer, B.S., M.D., 
Sc.D. 

William H. Park, A.B., M.D., 
LL.D. 

Clarence A. Patten, M.D. 

Howell T. Pershing, Ph.B., M.S., 
M.D., LL.D. 

Philip H. Pierson, B.A., M.D. 

Edwin Hemphill Place, M.D. 

Grover F. Powers, B.S., M.D. 

Joseph H. Pratt, A.M., M.D. 

John H. Pryor, M.D., F.A.C.P. 

Allan Ramsey, B.S., M.D. 

John Remer, A.M., M.D. 

Austin Fox Riggs, M.D. 

J. F. Rogers, M.D., D.P.H. 

Joseph C. Roper, M.D. 

Isador C. Rubin, M.D., F.A.C.S. 

Robert Dawson Rudolf, M.D., F.R. 
C.P. (London), C.B.E. 

John Ruhrah, M.D. 

Frederick Fuller Russell, M.D., 
Sc.D. 

Henry Sewall, B.S., Ph.D., M.D., 
Sc.D. 

George Elmer Shambaugh, Ph.B., 
M.D. 


F. C. Shattuck, A.B., A.M., M.D., 
LL.D., Sc.D. 

Henry Lamed Keith Shaw, M.D. 

P. G. Shipley, M.D. 

Burt Russell Shurly, B.S., M.D., 
F.A.C.S. 

Bertram Welton Sippy, M.D. 

William H. Smith, A.B., M.D. 

William Benham Snow, M.D. 

Abraham Sophian, M.D. 

Thomas P. Sprunt, A.B., M.D. 

Walter R. Steiner, A.B., M.A., 
M.D. 

Harry Eaton Stewart, M.D. 

John H. Stokes, A.B., M.D. 

Willard J. Stone, B.Sc., M.D. 

Richard Pearson Strong, Ph.B., 
M.D., Sc.D. 

Homer F. Swift, Ph.B., M.D. 

William B. Terhune, M.D. 

Kurt H. Thoma, D.M.D. 

W. Gilman Thompson, Ph.B., M.D. 

Wilder Tileston, A.B., M.D. 

Walter Timme, B.S., M.D. 

Frank P. Underhill, Ph.D. 

I. Chandler Walker, A.B., M.D. 

Theodore Weisenberg, M.D. 

Creighton Wellman, M.D. 

H. Gideon Wells, A.M., M.D., 
Ph.D. 

William Buchanan Wherry, A.B., 
M.D. 


XVI 


LIST OF CONTRIBUTORS 


Geo. H. Whipple, M.D. 

Paul Dudley White, A.B., M.D. 

Anna Wessels Williams, M.D. 

William R. Williams, A.B., A.M., 
M.D 

Edward J. Wood, B.Sc., M.D., 
D.T.M. (Eng.) 


Rollin T. Woodyatt, M.D. 

Paul Gerhardt Woolley, B.S., M.D. 

Wade Wright, B.S., M.D. 

Hugh Hampton Young, M.D., 
F.A.C.S. 

Edwin G. Zabriskie, M.D. 

Abraham Zingher, M.D., D.P.H. 


CONTRIBUTORS TO VOLUME I 


ANTON JULIUS CARLSON, A.M., Ph.D., M.D., LL.D. 

Professor of Physiology, University of Chicago and Rush Medical College, Consulting Physiolo¬ 
gist, St. Luke’s Hospital, Chicago 

Organotherapeutics 

WARREN COLEMAN, A.B., A.M., M.D. 

Assistant Professor of Medicine, University and Bellevue Hospital Medical College, Visiting 

Physician to Bellevue Hospital 

Nutrition and Dietetics 

MARTIN H. FISCHER, M.D. 

Joseph Eichberg Professor of Physiology, University of Cincinnati 

Some Physicochemical Principles in Therapy 

L. WHITTINGTON GORHAM, M.D. 

Clinical Professor of Medicine, Albany Medical College, Assistant Attending Physician, Albany 

Hospital 

Radium Therapy 

ERWIN G. GROSS, B.S., M.S., Ph.D. 

Assistant Professor Department of Pharmacology and Toxicology, Yale Medical School 

Nutrition and Dietetics 

CLINTON B. HAWN, M.D. 

Clinical Professor of Medicine, Albany Medical College, Assistant Attending Physician, Albany 

Hospital 

Radium Therapy 

WILLIAM VINCENT HEALEY, A.B., M.D. 

Chief of Clinic, The Reconstruction Hospital, New York City, Clinical Instructor in Surgery, 
Department of Orthopedic Surgery, Cornell University Medical College 

Mechanotherapy: Occupational Therapy 

WILLIAM J. M. A. MALONEY, M.D., Ch.B., LL.D., F.R.S. (Edin.) 
Neurologist to the Central and Neurological Hospital; Formerly Professor of Nervous Diseases, 

Fordham University, New York 

Hydrotherapy and Balneology 

THOMAS ORDWAY, M.D. 

Associate Professor of Medicine, Albany Medical College, Attending Physician, Albany Hospital 

Radium Therapy 

xvii 


XV111 


CONTRIBUTORS TO VOLUME I 


WALTER WALKER PALMER, B.S., M.D., Sc.D. 

Bard Professor of Medicine, College of Physicians and Surgeons, Columbia Unipersity, 
Medical Director, Presbyterian Hospital, New York City 

Physicochemical Principles in Therapy 

JOHN REMER, A.M., M.D. 

Radiotherapeutist, New York Hospital, Consulting Radiotherapeutist, United Hospital, Port- 
chester, N. Y., Vanderbilt Clinic, Department of Dermatology and Syphilology 

X-Ray Therapy 

HENRY SEWALL, Ph.D., M.D., Sc.D. 

Emeritus Professor of Medicine, University of Colorado 

Principles of Medical Climatology 

WILLIAM BENHAM SNOW, M.D. 

Editor of the "American Journal of Electrotherapeutics and Radiology’* 

Thermotherapy 

HARRY EATON STEWART, M.D. 

Attending Specialist in Physiotherapy, U. S. Public Health Service and U. S. Veterans’ 
Bureau; Director, New Haven School of Physiotherapy 

Introductory Remarks Concerning Physiotherapy, Massage, Exercise, 
Electrotherapy; Phototherapy; Practical Application of Com¬ 
bined Methods of Physiotherapy 

FRANK P. UNDERHILL, Ph.D. 

Professor of Pharmacology and Toxicology, Yale University 

Principles of Toxicology 


CONTENTS 


VOLUME I 

PRINCIPLES OF GENERAL THERAPY 

CHAPTER I 

SOME PHYSIOCHEMICAL PRINCIPLES IN THERAPY 
Martin H. Fischer 
Revised by Walter W. Palmer 

The General Constitution of Living Matter .... 

The Colloids .. 

The Crystalloids ......♦• 

Water . . . . • • • 

Standard Solutions and Comparative Methods in Pharmacology 
Equilibrium .....••••• 

Diffusion 

Distribution 

Causes of Inequalities in Distribution. 

Inequalities in Solubility 

Inequalities in Distribution Due to Inequalities in Adsorption 

Specific Chemical Differences. 

Interference from “Membranes”. 

Pharmacological Importance of Theory of Electrolytic Dissociation 
Effect of Various External Conditions on Colloidal State . 

Effect of Colloids on Crystalloids. 

Survey of Application ....•••• 
Role of Water 

Absorption and Secretion of Dissolved Substances 
Osmosis and Question of Cellular “Membranes” 

References. 

CHAPTER II 

NUTRITION AND DIETETICS 
Warren Coleman 
Revised by Erwin G. Gross 

Foods . • • • • • 

Foodstuffs. 

Proteins. 

Carbohydrates . • • • 

Fats . 


PAGE 

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6 

9 

11 

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20 

22 

22 

22 

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70 


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CONTENTS 


xx 

Foods ( Continued ) 


Foodstuffs ( Continued ) 

Vitamins .... 







PAGE 

71 

Inorganic Substances 







71 

Uses of Food .... 







71 

Uses of Proteins 







71 

Uses of Carbohydrates 







72; 

Uses of Fat 







72; 

Uses of Water .... 







73 

Uses of Salts .... 







73 

The Vitamins .... 







74 

Vitamin (A) .... 







74 

Vitamin (B) .... 







75 

Vitamin (C) .... 







76 

Vitamin (D) .... 







76 

Selection of Vitamin Diets 







76 

Condiments .... 







82 

Acid-Forming and Base-Forming Foods 






82 

Total Food Requirement 







85 

Age . . . . 







86 

Size ..... 







87 

Muscular Work 







87 

Protein, Fat, and Carbohydrate Ratios 






90 

Protein Requirement 







90 

The Carbohydrate Fat Requirement 







93 

Method of Reckoning the Protein, 

Fat a 

nd 

Carbohydrate Ration 

for 


Diets of Definite Energy Values 







95 

The Effects of Cooking upon Food . 







104 

Cooking Meats 







106 

Cooking Vegetables and Losses Incurred 






106 

Breadmaking .... 







107 

Cereal Breakfast-Foods . 







107 

Digestibility of Foods 







108 

General Considerations 




* 


108 

Digestibility of Meats 




4 

! . 


110 

Digestibility of Fish 







111 

Digestibility of Eggs 



. 

* { 

c 


111 

The Digestibility of Milk . 




. \ 

1 . 


112 

Digestibility of the Carbohydrates 



• 4 • 

1 

• i 

r 

£ • 


113 

Digestibility of Fat . 



• I • 

•I 

1 . 


114 

Length of Time Food Remains in I 

Stomach 


. f 

1 


115 

Effects of Starvation 



• i • 


\ 


117 

Effects of Complete Starvation . 



i 


l \ 


117 

Effects of Partial Starvation . 



. A- 




118 

Effects of Overfeeding . . . 



i . ‘ 


[: 


119 

Methods of Artificial Feeding . 



f, 




120 

Rectal Feeding 



. | . i 




120 

Gavage ..... 







122 

Subcutaneous Feeding 



' • 1 

y 



123 













CONTENTS 


XXI 


PAGE 

The Salt-Poor Diet 4 124 

The Purin-Free Diet .......... 127 

Metabolism in Fever .......... 128 

Total Metabolism .......... 128 

Quantitative Changes ......... 129 

Qualitative Changes ......... 130 

Nitrogen Metabolism ......... 131 

Absorption of Food in Fever ........ 134 

Fever Diet ............ 134 

Invalid’s Dietary ........... 136 

Proprietary Foods ........... 143 

References ............ 151 


CHAPTER III 
PRINCIPLES OF TOXICOLOGY 
Frank P. Underhill 


Classification of Poisons .......... 155 

Irritants ............ 155 

Nerve Poisons .......... 155 

Blood Poisons ........... 155 

Conditions Modifying Effects of Poisons ....... 155 

Poisons and Methods of Administration ...... 156 

Physical State or Form of a Poison ....... 156 

Path of Absorption . . . . . . . . . . 156 

Poison and Its Relation to the Organism ...... 157 

Age . . . . • . . . . . . . 157 

Idiosyncrasy ........... 157 

Habit. .158 

Tolerance ........... 158 

Disease ............ 158 

Fate of Poisons ........... 159 

Symptomatology of Poisons ......... 159 

Nausea, Vomiting and Purging ....... 160 

Vasomotor Disturbances ......... 160 

Cerebral Symptoms .......... 160 

Temperature ........... 160 

. Pulse.160 

Respiration ........... 160 

Motor Disturbances .......... 160 

•The Eye. ,161 

The Ear.161 

Modified Sensations ......... 161 

Skin Lesions ........... 161 

Diagnosis of Poisoning .......... 161 

Treatment of Poisoning . . . . . . . . . .162 

Removal of Poison .......... 162 

Administration of Antidotes ........ 164 

















xxii CONTENTS 

Treatment of Poisoning ( Continued ) 

Symptomatic Treatment .... 
Antidotes for First Aid .... 
References ....... 


PAGE 

165 

166 
167 


CHAPTER IV 

THE PRINCIPLES OF MEDICAL CLIMATOLOGY 
Henry Sewall 

Scope of the Subject 
Meteorological Climatology 
Atmospheric Humidity 
Winds . 

Altitude . 

Soil 

Electricity 

Composition of the Atmosphere 
Barometric Pressure 

Dust and Impurities in the Atmosphere 
The Influence of Vegetation on Climate 
Physiological and Medical Climatology . 

The Physiological Reaction to External Temperature 
Physiological Influence of Atmospheric Humidity 
Ventilation ....... 

The Physiological Influence of Diminished Barometric 
Insolation .... 

Dust and Atmospheric Impurities 
The Psychology of Climate 
Application of Climate to Treatment of Disease 
Tuberculosis 
Anemia 
Gout 

Rheumatoid Diseases 
Respiratory Affections 
Heart Diseases 
Disorders of Digestion 
Skin Diseases . 

Disorders of the Kidneys 
The Nervous System 
References 


Pressure 


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170 

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183 

187 

188 
191 
196 
198 
200 
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204 

205 
205 

205 

206 
206 
206 
206 
207 


CHAPTER V 

PHYSIOTHERAPY, MASSAGE, EXERCISE 
Harry Eaton Stewart 


Physiotherapy 

Athletic Injuries 


211 

214 


















CONTENTS xxiii 

Physiotherapy ( Continued ) PAGE 

General Hospital Practice ........ 214 

Medical School Curriculum ........ 214 

Massage ............ 215 

Definition ..215 

History.215 

Requirements for Hospital and Clinical Departments of Physiotherapy 216 
Personnel ........... 216 

Floor Space.216 

Apparatus ..216 

Post-war Reconstruction ......... 217 

Industrial Accidents ......... 217 

General Considerations ......... 218 

Types of Movement? . . . . . . . . 220 

General Indications .......... 224 

General Massage—Regional Technic ....... 224 

The Arm ........... 224 

The Leg ............ 225 

The Abdomen ........... 226 

The Chest ........... 226 

The Back ..226 

Summary ............ 227 

Exercise. 227 

Physiology of Exercise ......... 228 

Physical Education .......... 231 

Types of Exercise . . . . . . . . . 231 

The Child.232 

The Adolescent .......... 232 

The Adult.234 

Setting-Up Exercises ..234 

Theory of Medical and Orthopedic Gymnastics.235 

Types of Exercise .......... 235 


CHAPTER VI 
MECHANOTHERAPY 
William V. Healey 

Historical and Introductory 
Therapeutic Effects of Exercise 

Effect of Exercise on Digestion 
Effect of Exercise on Nervous System 
Effect of Exercise on Genito-Urinary System 
Effect of Exercise on Metabolism 
Physiology of Muscles .... 
Classification of Gymnastic Movements . 

General Exercise . . • 

Passive Movements 

Mechanical Aids .<>.<>• 


240 

241 
243 

243 

244 

244 

245 

246 

247 

248 

249 

















xxiv CONTENTS 

Classification of Gymnastic Movements ( Continued ) page 

Upper Extremity .......... 252 

Lower Extremity .......... 257 

Indications and Contra-indications ....... 261 

Indications . . . . • • • * * • 261 

Contra-indications .......... 262 

References ............ 263 

CHAPTER VII 
OCCUPATIONAL THERAPY 

William V. Healey 

Introduction ........... 264 

Types of Remedial Work ......... 268 

Application of Work . . . . . . . . .276 

References ............ 280 

CHAPTER VIII 
ELECTROTHERAPY 
Harry Eaton Stewart 

Galvanic or Constant Current ......... 281 

Sources ............ 281 

Apparatus.281 

Physics.281 

Galvanic Cell ........... 282 

Batteries ........... 282 

Electrical Terms .......... 282 

Physiological Effects ......... 283 

Polarity Tests ........... 284 

Therapeutic Uses of Galvanic Current ...... 284 

Treatment ............ 286 

Technic.286 

Electrodes .......... 286 

The Patient ........ 287 

Precautions ........ 288 

The Galvanic Bath ........ 289 

Local Treatments ....... 289 

Schnee Bath ....... 289 

General Galvanic Bath. 290 

General Galvanization ..... 290 

Ionization ....... ... ^ 

Definition . * 0Qn 

; ; ; ; 29 ° 0 

Chemistry .... 9Q1 

Technic. \ \ m 

Advantages of Ionization . 293 

Disadvantages of Ionization . 9Q n 




















CONTENTS 





XXV 

Ionization ( Continued ) 






PAGE 

Treatments ..... 






. 293 

Typical Treatment .... 






. 293 

Surgical Ionization .... 






. 293 

Interrupted and Wave Galvanic Currents 






. 294 

Interrupted Galvanic Current 






. 294 

Sources ...... 







Physiological Effects 






. 295 

Wave Galvanic Currents 






. 295 

Sources and Apparatus 






. 295 

Physiological Effects 






. 296 

Sinusoidal Currents .... 






. 296 

Definition ..... 






. 296 

Physics ...... 






. 296 

Physiological Effects 






. 297 

Technic ...... 






. 298 

Earadism ...... 






. 299 

Definition ..... 






. 299 

History ...... 






. 299 

Physics ...... 






. 299 

Physiological Effects 






. 300 

Technic of Earadic Treatment . 






. 300 

Treatment of Obesity 






. 302 

Combined Currents .... 






. 303 

High Frequency Currents 






. 304 

Diathermy ...... 






. 304 

Definition ..... 






. 304 

History ...... 






. 304 

Physics ...... 






. 305 

The Spark Gap and Its Proper Care . 






. 306 

The Milliamperemeter and Its Significance 





. 306 

Physiological Effects 






. 307 

Local Effects ..... 






. 307 

General Effects .... 






. 307 

Experiments ..... 






. 307 

The Machine ..... 






. 309 

Electrodes ..... 






. 310 

General Technic .... 






. 310 

Special Technic .... 






. 312 

Autocondensation .... 






. 313 

Precautions ..... 






. 314 

Contra-indications .... 






. 314 

Surgical Diathermy .... 






. 314 

Definition . 






. 314 

Technic ...••• 






. 315 

Unipolar and High-Frequency Currents . 






. 316 

Tesla and Oudin Currents 






. 316 

Vacuum Electrodes 






. 316 














xxvi CONTENTS 

Unipolar and High-Frequency Currents ( Continued ) page 

Physiological Effects.317 

Technic.318 

Static Electricity ........... 319 

Definition ........... 319 

Uses.319 

History.319 

Apparatus ........... 320 

Care of Apparatus .......... 320 

Charging ........... 321 

Polarity ............ 321 

Physics and Physiological Effects ....... 321 

Modalities . . .• . . . . . . . . 322 

Morton Wave ........... 323 

Sparks ............ 323 

Effluve ............ 325 

Induced Current .......... 325 

The Simple Charge .......... 326 

CHAPTER IX 
PHOTOTHERAPY 
Harry Eaton Stewart 

Light-Therapy in General ......... 327 

History.327 

Physics.327 

Penetrability.328 

Absorption ........... 329 

Pigmentation ........... 329 

Heliotherapy ............ 329 

Physiological Effects ......... 330 

Technic.. 

Indications ........... 331 

Contra-indications .......... 331 

Radiant Light. 331 

Definition ........... 331 

Therapeutic Effect .......... 332 

Local Effects ........... 332 

General Effects.. 

Apparatus. 333 

Carbon Arc Light .......... 333 

Technic. , 334 

Therapeutic Indications ......... 334 

Contra-indications .......... 335 

Ultraviolet, Quartz or Actinic Rays ........ 335 

Definition .......... 335 

Histor y.. 

Physics and Physiological Effects. 335 

Penetration ......... ggg 

























CONTENTS 

Ultraviolet, Quartz or Actinic Rays ( Continued) 
Yariation ...... 

Local Effects ...... 

General Effects ..... 

Apparatus ...... 

Technic ....... 

Treatment Precautions .... 

Therapeutic Indications .... 

Contra-indications ..... 


xxvii 

PACE 

. 336 
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. 339 
. 342 
. 346 

. 347 
. 347 


CHAPTER X 
THERMOTHERAPY 


William Benham Snow 


History .. 

Forms of Heat.350 

Conductive Heat . 350 

Convective Heat .......... 350 

Conversive Heat .......... 351 

D’Arsonval Currents .... ..... 352 

Direct or Bipolar D’Arsonval Current ...... 353 

Physics.354 

Action of Conversive Heat ........ 356 


Hyperemia ..357 

Increase of Nutrition ......... 357 

Metabolic Effects .......... 358 

Effects of, on Infection ......... 358 

Derivative Effects .......... 358 

Advantages of . .360 

Apparatus ............ 361 

Ultraviolet Rays .......... 361 

Hofmann Quartz Carbon Arc Lamp ....... 361 

Incandescent Light .......... 363 

Small Therapeutic Lamps and Applicators . . . ... . 365 

Multiple Light Reflectors ......... 366 

Dry-Hot-Air Apparatus ......... 368 

Hydrotherapeutic Apparatus ........ 370 

High Frequency Apparatus ........ 371 

Electrodes for Special Application . . . . . . .375 

Autocondensation . . . . . . . . .376 


General Principles of Technic in Thermotherapy . . . . .376 

Skin Toleration .......... 377 

Time of Application ... . 377 

Technic of Radiant Light and Heat Applications.377 


Position.377 

Distance . ... 377 

Extent of Exposure.377 

Length of Exposure ......... 377 
































xxviii CONTENTS • 

Technic of Eadiant Light and Heat Applications ( Continued ) 
Large Applicators 
Light Baths 

Technic of the Oven Bath 
Local Hot-Air Baths 
Technic for Administering Hydrotherapy 
The Wet Pack 
The Whirlpool Bath 
Therapeutics of Heat 
Heat Therapy . 

Treatment of Special Conditions of Infection 
Boils 
Abscesses 
Quinsy 

Felons and Whitlows 
Acute Otitis Media . 

Chronic Purulent Otitis Media 
Mastoiditis 
Coryza 
Sinusitis 

Suppurative Conditions 
Purulent Conjunctivitis 
Foreign Bodies 
Erysipelas 

Local Septic Infection 
Indurated Acne 

Fungus Infections of Skin and Scalp 
Urticaria and Hives 
Treatment of Pulmonary Conditions 
Bronchitis, Acute and Chronic 
Pneumonia 
Cholecystitis 
Catarrhal Appendicitis 
The Liver 

Stomach and Duodenum 
Nephritis . 

Body Oven 
Specific Vesiculitis . 

Gonorrheal Arthritis 
Dysmenorrhea . 

Subinvolution . 

Amenorrhea 
Uterine Hemorrhage 
Salpingitis 
Ovaritis . 

Non-infective Local Conditions 
Desiccation or Endothermy 
Impaired Metabolism 

Postoperative Use of Eadiant Light and Heat 


. 378 

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. 401 

. 402 












CONTENTS 


XXIX 


The Opposite Effects of the X-ray and Radiant Light .... 402 

Chronic X-ray Dermatitis.. 

Osteomyelitis. 4 Q 3 

References .. 4 Q 3 

CHAPTER XI 

HYDROTHERAPY AND BALNEOLOGY 
William J. M. A. Maloney 

Hydrotherapy.. 

History. 405 

Properties of Water.. 

Cold .410 

Heat . 413 

Mode of Application .......... 415 

General Baths ........... 416 

Application of Extreme Temperatures.423 

General Observations ......... 424 

Special Hydrotherapy . . . . . . . . . .425 

Diseases of the Circulatory System ....... 425 

Arteriosclerosis .......... 426 

Endocarditis ........... 426 

Hemorrhoids ........... 427 

Acute Pericarditis .......... 427 

Diseases of the Respiratory Tract ....... 427 

Asthma ............ 427 

Acute Bronchitis .......... 428 

Edema of the Lung .......... 428 

Hyperemia of the Lung ......... 428 

Pleurisy ............ 428 

Constitutional and Metabolic Diseases ....... 429 

Anemia ............ 429 

Diabetes Insipidus .......... 429 

Diabetes Mellitus .......... 429 

Exophthalmic Goiter ......... 430 

Obesity ............ 430 

Podagra ............ 431 

Chronic Articular Rheumatism ........ 431 

Muscular Rheumatism ......... 432 

Diseases of Genito-Urinary System ....... 432 

Bladder ............ 432 

Kidneys ............ 432 

Prostate and Urethra ......... 433 

Salpinx-Uterine-Ovarian ......... 434 

Testicle. 435 

Diseases of Gastro-Intestinal Tract . . . . . . . 435 

Biliary-Hepatic . . . • * • • • • * 435 



































xxx CONTENTS 

Diseases of Gastro-Intestinal Tract ( Continued ) 
Enteric Diseases ..... 

Gastric Diseases ..... 

Specific Infectious Diseases .... 

Diphtheria ...... 

Influenza ....... 

Exanthemata ...... 

Syphilis ....... 

Tetanus ....... 

Pulmonary Tuberculosis .... 

Yellow Eever . . . . 

Asiatic Cholera ..... 

Cholera Infantum ..... 

Dysentery ...... 

Typhoid Eever ...... 

Malaria ....... 

Cerebrospinal Meningitis .... 

Pneumonia ...... 

Diseases of the Nervous System . 

Cerebral Anemia ..... 

Cerebral Hemorrhage .... 

Cerebral Hyperemia .... 

Chorea . . . . • 

Epilepsy ....... 

Headache ...... 

Hemicrania ...... 

Hysteria ....... 

Insomnia ....... 

Acute Myelitis ..... 

Chronic Myelitis ..... 

Neuralgia ...... 

Neurasthenia ...... 

Neuritis ....... 

Occupation Neuroses ..... 

Paralysis ....... 

Tabes Dorsalis ...... 

Spasmodic Tic ...... 

Mania ....... 

Diseases of the Joints ..... 

Rheumatoid Arthritis .... 

Arthritis Deformans .... 

Gonorrheal Arthritis .... 

Acute Articular Rheumatism . 

Alcoholism ...... 

Chronic Arsenic Poisoning 

Chronic Mercurialism .... 

Chronic Morphinism .... 

Chronic Plumbism ..... 


PAGE 

435 

437 

438 

438 

438 

438 

439 

440 

440 

441 

441 

441 

442 

442 

443 

443 

444 

444 

444 

445 

445 

445 

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445 

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447 

448 

448 

448 

448 

449 

449 

449 

450 

450 

450 

450 

450 

450 

451 

452 

452 

452 

452 

452 













CONTENTS 


Diseases of the Joints ( Continued ) 
Chronic Nicotinism . 

Thermic Fever 

Balneology .... 
Introduction 

Composition of Mineral Waters 

Temperature 

Radio-activity . 

Classification 

Simple Thermal Waters . 
Common Salt Waters 
Alkaline Waters 
Bitter Waters . 

Chalybeate or Iron Waters 
Calcareous Group 
Sulphur Waters 
Arsenical Waters 
The Action of Mineral Waters 
Action of Salines 
Alkalies .... 


Iron, Arsenical, Sulphide, and Earthy 
Resultant Action of Mineral Waters 
Indications for, and Choice of, a Spa 
Climate of Spa .... 

The Spa Itself .... 

Tardy Convalescence . 

Special Balneology .... 
Diseases of the Blood 
Diseases of the Respiratory Organs 
Cardiac Diseases 
Renal and Bladder Diseases 
Rheumatism .... 
Alimentary Disorders 
References ..... 


Wat 


xxxi 

PAGE 

452 

452 

453 
453 

455 

456 

456 

457 
457 

457 

458 
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459 
459 
459 

459 

460 

460 

461 
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461 
465 
465 

465 

466 
466 

466 

467 

467 

468 

468 

469 


CHAPTER XII 

PRACTICAL APPLICATION OF COMBINED METHODS OF PHYSIOTHERAPY 


Harry Eaton Stewart 

Diseases and Injuries of the Neuromuscular System ..... 471 

Central Motor Neuron Lesions ........ 471 

Birth Hemiplegia in Children . . . . . . . .471 

Hemiplegia Following Cerebral Hemorrhage ..... 471 

Cerebral Degeneration . . . . • • • . .472 

Encephalitis Lethargica . . . . . • • • .472 

Cord Lesions—Infantile Paralysis ....... 472 

Passive Exercises .......... 473 

Exercises with Carriage . . • • • • • • .4/3 

















XXXI1 


CONTENTS 


PAGE 

Free Exercises 474 

Resistive Exercises . . . . . • • • • .475 

Peripheral Nerve Lesions . . . . . . . . .477 

Muscle Nerve Testing ......... 477 

Apparatus and Technic . . . . . . . . .479 

Electrical Diagnosis at Operation ....... 480 

Treatment o,f Peripheral Nerve Injuries ...... 480 

Neuroma ............ 482 

Neuralgia ........... 482 

Volkmann’s Contracture ......... 482 

Acute Neuritis .......... 482 

Chronic Neuritis . . . . . . . . . 482 

Brachial Neuritis .......... 482 

Sciatic Neuritis .......... 483 

Neurasthenia ........... 483 

Toxic Myositis ........... 483 

Traumatic Acute Myositis ........ 484 

Torn Muscle Insertions ......... 484 

Tenosynovitis ........... 484 

Diseases and Injuries of the Bones and Joints . . . . . . 485 

Fractures ........... 485 

Rickets . . . . . . . . . . . - . 485 

Osteomyelitis ........... 486 

Tuberculous Osteitis ......... 487 

Periostitis ........... 487 

Traumatic Arthritis .......... 487 

Toxic Arthritis .......... 488 

Arthritis Deformans ......... 488 

Gout.489 

Infectious Arthritis .......... 489 

Tuberculous Arthritis ......... 489 

Bursitis ............ 490 

Combined Conditions ......... 490 

Diseases of the Cardiovascular System ....... 490 

Hypertension and Arteriosclerosis ....... 490 

Hypotension ........... 491 

Phlebitis ............ 492 

Endarteritis Obliterans ......... 492 

Anemia and Chlorosis ....... 492 

Organic Valvular Lesions of the Heart .... . 493 

Myocarditis ........... 494 

Intermittent Claudication ........ 494 

Functional Cardiac Disturbances ....... 495 

Shott-Nauheim Exercises ......... 497 

Diseases of the Gastro-Intestinal Tract ....... 498 

Pyorrhea and Apical Abscess ........ 498 

Gastritis ............ 498 

Cholecystitis ........... 498 













CONTENTS 

Diseases of the Gastro-Intestinal Tract ( Continued ) 
Appendicitis ...... 

Gastric and Duodenal Ulcers . 

Visceroptosis ...... 

Chronic Constipation .... 

Sigmoid Impaction ..... 

Hemorrhoids and Anal Fissures 
Internal Hemorrhoids .... 

Fissures ....... 

Diseases of the Kespiratory System . 

Coryza ....... 

Tonsillitis ...... 

Diphtheria Carriers ..... 

Tubercular Laryngitis .... 

Gas Laryngitis ..... 

Sinusitis ....... 

Bronchitis ...... 

Bronchopneumonia ..... 

Lobar Pneumonia ..... 

Pulmonary Tuberculosis .... 

Pleuritis ....... 

Empyema ...... 

Adhesions ...... 

Diseases and Injuries of the Skin 

Alopecia ....... 

Alopecia Areata ..... 

Acne ....... 

Angioma ....... 

Burns ....... 

Boils ....... 

Carbuncles . . ... 

Callosities ...... 

Eczema ....... 

Epithelioma . 

Erysipelas ...... 

Erythema Indu^atum .... 

Leukoderma ...... 

Lupus ....... 

Nevi ....... 

Pso^^a ...... 

Pruritu. ...... 

Tinea ....... 

Telangiectasis . 

Ulcers ....... 

Diseases of the Genito-Urinary System . 

Amenorrhea ...... 

Dysmenorrhea ...... 

Endometritis ...... 

Cervical Erosions . 


xxxiii 

PAGE 

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xxxiv CONTENTS 

Diseases of the Genito-Urinary System ( Continued ) page 

Infantile Uterus .......... 521 

Pelvic Inflammatory Conditions ....... 522 

# Enuresis ............ 523 

Gonorrhea ........... 523 

Prostatitis ........... 523 

Nephritis ........... 524 

Diseases of Glands; Diseases of the Ear; and Scars ..... 524 

Cystic Goiter ........... 524 

Exophthalmic Goiter ......... 526 

Adenitis ............ 526 

The Ductless Glands ......... 526 

Otitis Media ........... 527 

Catarrhal Deafness .......... 527 

Scars ............ 527 

Postural Defects ........... 529 

Head and Shoulders ......... 530 

Kyphosis ............ 530 

Lordosis ............ 531 

Scoliosis ............ 532 

Diagnosis ........... 532 

Other Physiotherapeutic Measures ....... 535 

Foot Disabilities ........... 535 

Treatment ........... 538 

Deferences ^ . 539 

CHAPTER XIII 
RADIUM THERAPY 

Thomas Ordway, L. Whittington Gorham and Clinton B. Hawn 

Kadium ............ 543 

Injuries Incidental to Handling Kadium ...... 545 

Action of Radium, Local and General . . . . . . 551 

Comparison of X-ray and Radium ....... 552 

Medicinal Use of Radium ...... i 554 

Physiological Action of Emanation ....... 555 

Therapeutic Effects of Radio-Active Substances ..... 556 

Arthritis Deformans ......... 556 

Acute Articular Rheumatism ........ 556 

Chronic Arthritis .......... 556 

Gonorrheal Arthritis ......... 557 

Tuberculosis of Joints ......... 557 

Gout. 557 

Leukemia ........... 558 

Miscellaneous Conditions ......... 560 

External and Surgical Use of Radium.561 

Methods of Application ......... 561 






























CONTENTS 


XXXV 


PAGE 

General Rules for Application of Radium ...... 563 

Further Details of Application ....... 564 

External Use of Radio-Active Substances ...... 568 

Diseases of the Skin ......... 568 

Diseases of Mouth, Nose, Throat, and Ear ..... 573 

Pathological Conditions of Glands . . . . . . .574 

Pathological Conditions of Chest . . . . . . .575 

Diseases of Breast . . . . . . . . . .575 

Abdominal Conditions . . . . . . . . .576 

Pelvic Diseases .......... 577 

Summary ........... 581 


CHAPTER XIV 
X-RAY THERAPY 
John Remer 

Introductory ..... ^ 

Physics ........ 

X-ray Tube 

Gas Tubes. 

Coolidge Tube ..... 

Transformer. 

Spark Gap ...... 

Ampere . . • • • 

Distance . . • • • • 

Time. 

Filter .. 

General Considerations of X-ray Therapy 
Effect of X-ray Therapy on Tissues . 

Skin 

Circulatory System. 

Eyes. 

Kidneys ...•••• 
Nervous System ..... 
Lungs 

Thyroid and Thymus .... 

Larynx 

Spleen 

Gastro-Intestinal Tract .... 
Reproductive Organs .... 
Pregnancy ...••• 
Bacteria . 

Radiodermatitis. 

Sequelae 

Treatment. 

Idiosyncrasy. 

Method of Computing X-ray Intensity or Dosage 
Unfiltered Radiation . 


. 583 

. 584 
. 584 

. 585 

. 585 

. 585 

. 586 

. 586 

. 587 

. 587 

. 587 

. 588 

. 590 

. 590 

. 590 

. 591 

. 591 

. 591 

. 591 

. 592 

. 592 

. 592 

. 592 

. 593 

. 594 

. 594 

. 594 
. 595 

. 596 

. 597 

. 598 
. 598 





















xxxvi CONTENTS 

Method of Computing X-Ray Intensity or Dosage ( Continued ) 
Filtered Radiation 
Unfiltered Treatment 
When Unfiltered Radiation May Be Used 
Rosacea, Per Se 
Lichen Planus . 

Psoriasis . 

Eczema 

Lupus Vulgaris 
Lupus Erythematosis 
Mycosis Fungoides . 

Tinea Tonsurans and Favus 
Blastomycosis and Actinomycosis 
Pruritus ..... 

Pruritus Ani et Vulvae 

Keloid. 

Dermatitis Papillaris Capillitii or Acne Keloid 
Epithelioma 

Prickle-Cell or Squamous-Cell Epithelioma 
Melanoma 
Acne 

Sycosis Vulgaris 
Hyperidrosis and Bromidrosis . 

Hypertrichosis .... 

When Filtered Radiation May Be Used 
Carcinoma .... 

Sarcoma ..... 

Uterine Fibroids 
Menorrhagia 

Chronic Mastitis and Fibromata of Breast 
Prostatic Hypertrophy 
Tonsils 

Hyperthyroidism 
Hodgkin’s Disease 
Leukemia 
Banti’s Disease 
Tuberculous Adenitis . 

Tuberculous Peritonitis 
Tuberculous Osteomyelitis . 

Pulmonary Tuberculosis . 

Sinusitis and Mastoiditis . 

Rose Cold and Hay Fever 
Asthma 
. Pneumonia 
Sinus Tracts 
Neuritis . 

Malaria 
Pertussis . 

Summary 


PAGE 

601 

604 

605 
605 

605 

606 

607 

608 
608 
608 
610 
612 
612 
612 
613 

613 

614 

614 

615 

615 

616 

617 

618 
618 
618 
620 
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622 
622 
622 
623 

625 

626 
627. 
628 
628 
629 
629] 
629 j 

629 

630 
630 
630 
630 

630 

631 
631 
631 














CONTENTS 


XXXVll 


CHAPTER XV 
ORGANOTHERAPEUTICS 
Anton Julius Carlson 


by 


Organotherapy 


Introduction . 

Definition .... 

Organ Transplantation 
History ..... 

General Principles of Organotherapy 
Hormone Substance Essential . 

Primary Hyperfunction Not Altered 
Dystrophy and Perverted Secretion 
Accumulation of Hormones 
Stability of Hormone 
Activity of Hormone 
Standardization of Products 
Clinical Control in Use of Organ Extracts 
The Dangers in Organotherapy . 

Early versus Late Therapy in Endocrine Hypofunctions 
Uniglandular versus Pluriglandular Organotherapy . 
Experimental versus Clinical Organotherapy 
A Complete Organotherapy Probably Not Attainable . 

The Thyroid .. 

Function of the Thyroid . 

Significance of the Thyroid Innervation . 

Chemistry of the Thyroid ...... 

Relation of the Iodin to Physiological Activity of the Thyr( 
Relation of the Thyroid to Diet 
Secretion versus Detoxication . 

The Thyroid Secretion and Body Fluids 
Relation of the Iodin to Histological Structure of the Thyroid 
Relation of Thyroid Hyperplasia to Thyroid Neoplasm 
Hyperthyroidism, Experimental and Clinical 
Toxic Goiter ...... 

Hypothyroidism in Childhood 

Cretinism ...... 

Hypothyroidism in the Adult 

Myxedema ...... 

Thyroid Administration in Hypothyroidism 
Thyroid Feeding in Conditions of Mild Hypothyroidism 
Effects of Thyroid Administration in Normal Individuals 
Indications for Use of Thyroid . 

Thyroid Organotherapy in Other Conditions 
Methods of Administering Thyroid 
Transplantation .... 

Subcutaneous Injections . 

Administration by Mouth . 


oid 


PAGE 

633 

633 

633 

634 
63 6 

636 

637 

638 

638 

639 

640 

641 

642 

643 

643 

644 

646 

647 

648 

648 

649 

650 

652 

653 

654 

654 

655 

656 
656 
656 
659 
659 
662 
662 
663 
665 
667 

667 

668 
670 
670 

670 

671 


















XXXV111 


CONTENTS 


PAGE 

Official and Other Preparations of Thyroid ...... 671 

Pharmacopeial Preparations ........ 671 

Tablets.671 

Extracts and Other Preparations . . . . . . . 672 

Untoward Effects and Contra-indications ...... 672 

Summary ............ 673 

The Parathyroids ........... 674 

Physiology ........... 674 

Extirpation of the Parathyroids . . . . . . .675 

Parathyroid Tetany and the Digestive Tract . . . . .676 

Parathyroid Tetany and the Liver ....... 677 

The Blood in Parathyroid Tetany . . . . . . .678 

Temporary Control of Experimental Parathyroid Tetany . . .679 

Administration by Mouth ........ 680 

Transplantation of Glands ........ 680 

Permanent Control of Parathyroid Tetany in Dogs .... 680 

Parathyroid Deficiency in Man ........ 682 

Parathyroid Organotherapy ........ 683 

Summary ............ 684 

The Pancreas ........... 685 

The Islands of Langerhans ........ 687 

Experimental Pancreatic Diabetes ....... 688 

Blood Transfusion .......... 691 

Parabiosis ........... 693 

Pregnancy ........... 693 

Transplantation of the Pancreas . . . . . . . 694 

Feeding Pancreas or Pancreas Extracts ...... 695 

Injection of Pancreas Extracts ........ 695 

Pancreas Hormones'in Pancreatic Perfusates ..... 696 

Relation of Pancreatic Diabetes in Animals to Clinical Diabetes . . 697 

Administration of Pancreas Preparation (Insulin) in Clinical Diabetes 

by the Mouth . . . . . . . . . . 698 

Subcutaneous and Intravenous Injections of Pancreas Preparations . 699 

Blood Transfusion .......... 699 

Relation of Other Endocrine Glands and Organs to Experimental and 

Clinical Diabetes ......... 699 

Summary ............ 701 

The Suprarenal Glands ......... 701 

Anatomy ........... 701 

Chemistry of Medullary Tissue ........ 703 

Tonus Theory of Adrenal Function ....... 704 

Emergency Theory of Adrenal Function ...... 705 

Theory of Epinephrin Control of Functions of Blood Capillaries . . 706 

Secretion of the Epinephrin ........ 706 

Pharmacological Actions of Epinephrin ...... 707 

Blood-Vessels ........... 707 

Heart.708 

The Coronary Circulation ........ 708 


















CONTENTS 


XXXIX 


Alimentary Tract . ■ 

Urinary Bladder. 

Uterus. 

Bronchial Muscles ....... 

Action on the Pupil ........ 

The Kidneys ......... 

Metabolism ....... 

Functions of the Adrenal Cortex. 

Cortex Essential to Life. 

Extirpation of the Suprarenals ........ 

Disease of the Suprarenal Glands ....... 

Hypo-adrenia and Hyperadrenia ....... 

Control of Experimental Adrenal Deficiency. 

Organotherapeutics in Suprarenal Deficiency in Man .... 

Other Conditions of Supposed Suprarenal Insufficiency . 
Pharmacological Uses ........ 

Preparation and Dosage of Epinephrin ...... 

Untoward Effects of Epinephrin ....... 

Summary ............ 

The Hypophysis ........... 

Structure of the Hypophysis . . . 

Accessory Hypophysis ......... 

Function of the Posterior Lobe and the Pars Intermedia 

Action of the Extract ......... 

Alleged Galactagogue Action of Posterior Lobe Extract . 
Standardization of Posterior Lobe Extracts ..... 

Feeding Experiments with Posterior Lobe ...... 

Function of the Anterior Lobe ........ 

Alleged Growth-Controlling Principle of Anterior Lobe 
Extirpation of Anterior Lobe ........ 

Transplantation of the Hypophysis ....... 

Direct Stimulation of the Hypophysis ...... 

Alleged Secretory Nerves to the Hypophysis ..... 

Effects of Feeding and of Injection of Anterior Lobe Extract, 
Experimental .......... 

Functional Disorders of the Hypophysis; Alleged Hyperpituitarism . 
Functional Disorders of the Hypophysis; Alleged Hypopituitarism . 
Summary ............ 

Therapeutic Uses of the Anterior Lobe ...... 

Therapeutic Uses of Extracts of Posterior Lobe (Pituitrin) 

General Summary .......... 

The Ovaries ............ 

Anatomy ........... 

Influences of Congenital Absence, Atrophy and Extirpation of Ovaries 
Ovarian Transplantation ......... 

Chemistry of Ovarian Extracts ........ 

Specific Bole of the Corpus Luteum ....... 

Alleged Antagonism between Testicular and Ovarian Hormones . 


PAGE 

708 

709 

709 

710 

710 

710 

711 

712 

712 

712 

714 

714 

715 

715 

715 

716 

718 

719 

719 

720 

720 

723 

724 

724 

726 

728 

728 

729 

729 

729 

730 

730 

731 

731 

733 

735 

737 

737 

739 

740 

740 

740 

741 

742 

743 

745 

747 






















CONTENTS 


xl 

The Ovaries ( Continued ) paob 

Experimental Administration of Ovarian Extract .... 748 

Therapeutic Use of Ovarian Preparations ...... 749 

Causes for Failure of Ovarian Therapy . . . . . .751 

Methods of Preparation and Administration ..... 752 

Summary ............ 752 

The Fetus and the Placenta . . . . . . . . .753 

Summary ............ 753 

The Mammary Gland .......... 754 

The Testes ............ 755 

Physiology ........... 755 

Influence of Congenital Absence, Atrophy, or Extirpation of Testicles 755 
Function of Interstitial Cells . . . . . . 757 

Relation of Interstitial Cells of Testes to Cortical Cells of Adrenals; 

Hypergenitalism . . . . . . . . .758 

Chemistry of Testes . . . . . . . . . .758 

Clinical and Experimental Uses of Testes Extracts . . . .758 

Transplantation of the Testes . . . . . . . * . 759 

Summary ............ 761 

The Prostate Gland .......... 761 

Summary ............ 762 

The Pineal Body ........... 762 

Injections of Pineal Extracts ........ 763 

Extirpation of the Pineal Body ....... 763 

Feeding Pineal Material . . . . . . . . .763 

Pineal Tumors .......... 764 

The Thymus . . . . . . . . . . . .764 

Physiology.764 

Pathology.767 

Therapeutic Uses of Thymus Extracts ...... 767 

Summary ............ 768 

The Spleen ............ 768 

Physiology.768 

Effects of Splenectomy in Normal Animals and Persons . . . 769 

Experimental Administration of Spleen and Spleen Extracts . . 769 

Hypofunction or Dysfunction of Spleen in Splenic Anemia, Hemolytic 

Jaundice, and Hanot’s Cirrhosis ....... 770 

The Spleen in Pernicious Anemia ....... 771 

Therapeutic Uses of Spleen and Spleen Extracts . . . .771 

Summary ............ 771 

The Gastric and Duodenal Mucosa ........ 772 

Secretins ............ 772 

Secretin Organotherapy ......... 773 

Diabetes Mellitus .......... 773 

Digestive Disturbances ......... 774 

Alleged Gastro-Intestinal Motor Hormone of Mucosa; “Hormonal”; 

Cholin ........... 774 



































CONTENTS xli 

The Gastric and Duodenal Mucosa ( Continued ) pag& 

Other Possible Hormone Functions of Intestinal Mucosa . . .775 

The Gastric Mucosa; Gastrin.776 

Summary.777 

The Blood ............ 777 

Blood Transfusion .......... 777 

Therapeutic Uses of Leukocytic Extracts . . . . . .778 

Hemoglobin Feeding . . . . . . . . .779 

Lymph-Gland Therapy . . . . . . . . .779 

Summary.779 

The Kidney ............ 779 

The Liver ............ 780 

Therapeutic Uses of Other Organ Extracts ...... 781 

Bone Marrow ........... 781 

Tumors ............ 781 

Muscle ............ 782 

Lung, Parotid Gland, Tonsils, Lymph Glands, Retina, Iris, Nasal 

Mucous Membrane, Etc. . . . . . . . .782 

Summary ............ 782 

References.. « » » . « . 782 




















LIST OF ILLUSTRATIONS 


NUTRITION AND DIETETICS 
Warren Coleman 
Revised by Erwin G. Gross 

FIGURE PAGE 

1. Chart for determining surface area of man in square meters from 

weight in kilograms and height in centimeters .... 86 

2. Chart showing variation of basal metabolism with age ... 87 

PHYSIOTHERAPY, MASSAGE, EXERCISE 


Harry Eaton Stewart 

1. A well-equipped electrotherapy room ...... 212 

2. Effleurage of the forearm ......... 218 

3. Petrissage of calf muscle ........ 220 

4. Use of body weight in stretching elbow adhesions .... 236 

5. Use of body weight in stretching adhesions of knee-joint . . . 237 


MECHANOTHERAPY 
William Y. Healey 

1. Eundamental positions from which exercises may be derived . . 248 

2. A few derived movements from the fundamental positions . . . 249 

3. Triplicate-pulley weight machine by which resistance may be offered 


upward, downward or in the horizontal direction .... 251 

4. Finger pulleys .......... 252 

5. Finger treadmill .......... 253 

6. Circumduction at the wrist ........ 254 

7. Abduction and adduction of wrist ....... 254 

8. Pronation and supination of wrist ....... 255 

9. Circumduction of ankle ......... 256 

10. Inversion and eversion boards ........ 257 

11. Stationary bicycle .......... 258 

12. Grip machine for improving flexion of the fingers and flexion and 

extension of the wrist ......... 258 

13. One type of protractor scale to measure range of motion . . .259 


14. Rosen type of apparatus for indicating range of motion at the 

metacarpal and phalangeal joints ....... 

15. Dynamometer for measuring grip of hand • 

xliii 

















xliv 


LIST OF ILLUSTRATIONS 


OCCUPATIONAL THERAPY 
William V. Healey 

FIGURE 

1. Rake knitting and tapestry making ....... 

2. Belt making ........... 

3. Basket making while confined to a wheel chair ..... 

4. Braiding rugs while convalescing ....... 

5. Weaving on hand looms in the ward ....... 

6. Rug and table cover weaving and painting for ambulatory cases 

7. Jig-saw work for ambulatory cases ....... 

8. Scarfs, table covers, baskets, toys, etc., products of occupational therapy 

9. Printing shop at the Dover Farms Industries, New York, where voca¬ 

tional training rehabilitates the crippled and disabled . 

10. Fly shuttle hand looms at the Dover Farms Industries, New York . 

11. Rug making at the Dover Farms Industries ..... 

12. Vocational rehabilitation at the Dover Farms Industries’ cabinet shop 

ELECTROTHERAPY 
Harry Eaton Stewart 

1. Interrupted galvanic ......... 

2. Slow surging galvanic ......... 

3. Slow sinusoidal .......... 

4. Rapid sinusoidal .......... 

5. Interrupted sinusoidal ......... 

6. Surging sinusoidal .......... 

7. The Polysine generator combining many types of contractile currents 

8. Portable high-frequency apparatus delivering 2,500 milliamperes of 

current ........... 

9. A standard type of high-frequency apparatus ..... 

10. Autocondensation for hypertension ....... 

11. The application of surface high-frequency ...... 

PHOTOTHERAPY 
Harry Eaton Stewart 

1. Body radiant light bath cabinet ....... 

2. The 1,500-candle-power radiant lamp with stand .... 

3. Mercury-Tungsten air-cooled ultraviolet lamp with rectifier and local 

applicator .......... 

4. The all-mercury air-cooled ultraviolet lamp with rectifier and counter 

weight ......... 

5. Standard of the water-cooled ultraviolet lamp with rectifier 

6. New type, portable, water-cooled, ultraviolet lamp for ward work 

THERMOTHERAPY 
William Benham Snow 

1. Quartz carbon arc lamp ....... 

2. Air-cooled mercury vapor lamp ..... 


PAGE 

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269 

270 

271 

271 

272 

272 

273 

275 

275 

276 

277 

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296 

296 

297 

297 

297 

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304 

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314 

317 

332 

333 

335 

338 

340 

342 

361 

362 
















LIST OF ILLUSTRATIONS xlv 

FIGURE page 

3. Combination air-cooled and water-cooled quartz lamps for alternating 

current ........... 363 

4. Reclining body light bath.. 364 

5. Illustrating the law of reflection.365 

6. Reflection from a parabola.365 

7. Incidence of a focus with the dark spot beyond the focal point . . 365 

8. Small hand lamp projecting parallel or slightly divergent rays . . 366 

9. Larger lamp of same type as Fig. 8 with stand.366 

10. Smaller type of multiple light reflector made adjustable for con¬ 

venience in transport ......... 367 

11. Larger type of multiple light reflector.368 

12. Gas-heated body dry-hot-air apparatus ...... 368 

13. Dry-hot-air apparatus for administration of heat to a leg or arm . 369 

14. The gas-heated dry-hot-air apparatus for treating the knee or elbow 

joint ............ 370 

15. The whirlpool bath .......... 371 

16. Arrangement for producing the agitation of the water in the whirl¬ 

pool baths ........... 372 

17. Complete coil equipment for high frequency and X-ray apparatus of 

the d’Arsonval type . . . . . . . . .372 

18. Arrangement of condensers, spark gap and selenoid . . . .373 

19. Modern type of multiple spark-gap interrupter regulated by increasing 

the spark length with all of the gaps constantly in circuit . .374 


PRACTICAL APPLICATION OF COMBINED METHODS OF 
PHYSIOTHERAPY 

Harry Eaton Stewart 

1. Passive extension of shoulder joint . . . . . . .473 

2. Pronation and supination machine . . . . . . .475 

3. Resistive exercises for development of leg stump . . . .476 

4. Measuring the strength of the muscles governing elbow extension in 

a forearm amputation case . . . . . . . .478 

5. Apparatus for measuring degree of return in joint function . . 481 

6. Cardiovascular class in army hospital.495 


RADIUM THERAPY 

Thomas Ordway, L. Whittinuton Gorham and Clinton B. Hawn 

1. Devices for holding brass capsule to avoid contact of the fingers . 

2. Further devices for avoiding contact of fingers with radium . 

3. Thick-sided lead box and cover to protect workers from radium radia¬ 

tions while making and applying applicators ..... 

4. Devices for protection against radio-active substances 

5A. A blood smear from a patient with myelogenous leukemia, taken 
before radium treatment ........ 

5B. A blood smear from a patient with myelogenous leukemia, taken 
during the course of radium treatment ..... 


546 

547 

548 

549 

557 

558 






xlvi 


LIST OF ILLUSTRATIONS 


FIGURE 

5C. A blood smear from a patient with myelogenous leukemia, taken after 
the course of radium treatment 

6. Equipment for treating small superficial lesion of the skin . ... 

7. Application for treating deep-seated lesion by surface application 

through the skin when the latter is intact and deep but not surface 
effect is desired ....•••••• 

8. Epithelioma of right ear ..••••••• 

9. Patient in Fig. 16 after radium treatment ...... 

10. Keloid of back of neck. Recurrence after surgical removal . 

11. Patient in Fig. 18 after radium treatment . . . . 

12. Lupus vulgaris of right cheek in girl aged 13 . 

13. Patient in Fig. 12 after radium treatment ..... 

14. Cavernous angioma of forehead ....... 

15. Patient in Fig. 14 after radium treatment. 

16. Pigmented hairy nevus of left eyebrow and forehead .... 

17. Patient in Fig. 16 after radium treatment. 

18. Lymphosarcoma of neck ......... 

19. Patient in Fig. 18 after radium treatment . 


PAGE 

559 

565 


566 

568 

569 

570 

570 

571 

571 

572 
572 
572 
572 

574 

575 


ORGANOTHERAPEUTICS 
Anton Julius Carlson 

1. A normal rabbit and two absolute cretins from the same litter. Age 

three months .......... 660 

2. Skin lesions developed in thyroid-fed absolute cretins five months after 

discontinuing the thyroid treatment ...... 661 

3. Thyroid deficiency in the tadpole ....... 663 

4. Growth curves of four normal and three absolute cretin rabbits, same 

litter ............ 664 

4B. Growth curves of four normal control rabbits, five absolute cretins, 

and eight absolute cretins fed standard U.S.P. Thyroid Extract 664 
4C. Growth curves of four normal control rabbits, two absolute cretins, 
and six absolute cretins transfused repeatedly with hyperthyroid 
blood serum .......... 665 

5. Microphotograph (X 38) of a portion of the pancreas of the guinea pig 

stained intra vitam by neutral red ...... 686 

6. Pancreatic duct with branches showing the highly branched tubules 

connected with the duct and with an islet ..... 688 

7. Small portion of an islet of Langerhans of the guinea pig . . . 690 

8. Charts showing absence of hyperglycemia and diabetes after complete 

pancreatectomy in late pregnancy ...... 694 

9. Section of suprarenal of child twelve days old, low power . . .702 

10. Effects of intravenous injection of adrenal extract (epinephrin) on 

the heart and the blood-pressure . . . . . .704 

11. A, stimulation effect of epinephrin on the rabbit’s uterus. 

B, inhibitory effect of epinephrin on the uterus of the rat. 

C, inhibitory effect of epinephrin on the cat’s intestine . . . 709 






LIST OF ILLUSTRATIONS 


xlvii 


FIGURE 

12. Mesial sagittal section through the pituitary body of an adult monkey 

(semi-diagrammatic) ......... 

13. Twelve-months’-old hypophysectomized dog (left) and control of same 

litter (right) .......... 

14. Adult dogs, male and female, some months after removal of the 

greater part of the pituitary body. 

15. Tracing showing the effect of intravenous injection of extract of the 

posterior lobe of the hypophysis on the blood-pressure . 

1G. Tracing showing the action on an isolated cornu of rat’s uterus sus¬ 
pended in Locke’s solution of the addition of extract of posterior 
lobe of ox pituitary to the solution .. 

17. Tracing showing the contraction of musculature of the mammary 

gland duct system of the goat on intravenous injection of pituitrin 

18. Diagrammatic representation of the sexual cycle .... 

19. Effect of spaying on growth in the white rat ..... 

20. Record of dog showing reaction to 0.5 cubic centimeter nicotin 

(1:2,000 dilution), a, before, and b, 46 days after extirpation of 
the ovaries ........... 

21. Composite curves showing blood-pressure responses to standard doses 

of nicotin ........... 

22. Chart showing the weight of the thymus of the albino rat according 

to age ............ 

23. Tracings showing practically complete destruction of secretin by the 

gastric juice ...... .... 


PAGE 

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736 

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739 

741 

744 

746 

749 

765 

773 
















PRINCIPLES OF 
GENERAL THERAPY 



CHAPTER I 


SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 
Martin H. Fischer 
Revised by Walter W. Palmer 

It is safe to say that the ultimate test of every teaching in medicine 
and surgery lies in prognosis and therapy. A correct prognosis means 
that we understand the course of the diseased process with which we are 
dealing; it is favorable if we are able to retard, stop, or reverse the series 
of physical or chemical changes that have placed a patient in the diseased 
state in which we find him; or unfavorable if we are unable to do this. 
A successful therapy means that we not only understand this matter of 
prognosis, hut also that we have at our disposal appropriate measures 
by which we may retard, stop, or reverse the course of the diseased 
process. 

We like to believe, and aim to make, our therapy rational. Through 
the ages there have come down to us the results of the observations of 
many men who, seeing that a diseased process was modified, say through 
the laying on of hands, or through the consumption of sea-weed, have 
recommended such procedures subsequently to patients similarly afflicted. 
Such therapy is not rational, hut empirical. But just because it is em¬ 
pirical it is not to be despised. A therapeutic procedure that brings good 
results is never to be despised; it usually merely represents the phe¬ 
nomenon of a practical result that, has been attained sooner than the 
interpretation of the mechanism of this result. So, to return to our 
illustration, we recognize in the laying on of hands the psychotherapy 
of to-day, and in the administration of sea-weed the consumption of 
iodids. 


3 


4 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 

But, while we may not despise any good therapeutic procedure just 
because it is empirical, we have every reason to despise the modern ther¬ 
apist who employs the empirical method where a rational one is at hand, 
or who employs the empirical method in the hope of winning thereby 
new and valuable means of combating disease. Such may result, but the 
methods employed are uneconomical. So, instead of exhausting a pharma¬ 
copeia and the time of a hundred workers in trying to find a curative 
agent for myxedema, it is better to understand the physiology and the 
pathological physiology of the thyroid gland, and then the beneficent ef¬ 
fects of the administration of thyroid gland can almost be told in advance. 

What we have just illustrated by reference to myxedema holds true 
for all our therapy, whether we would practice, as far as possible, a ra¬ 
tional therapy now, or whether we are interested in the advancement of 
this branch of medicine. We ignore the fact too completely in medicine 
that a rational therapy can be built only upon a rational pathology, and 
that a rational pathology is impossible without a knowledge of physiology. 
Physiology, which is to-day a mere gargoyle, will yet become the key¬ 
stone of a modern medicine. 

When we have realized these simple truths for the good of the devel¬ 
opment of a scientific therapy, we need next to appreciate the fact that 
the unit for consideration in physiology, and so in pathology and therapy, 
is the cell. As we are practical men in medicine, we are likely to lose 
sight of this fact, or to take exception to it, and yet the most practical 
man, as we shall see, will heed the physiology of the cell most. The 
reasons for this are obvious. 

When a man falls ill, be the cause what it may, he does not do this 
“all over.” Only individual parts of the body may be affected or some 
parts of the body are affected sooner or more intensely than others. So 
a man may be poisoned by an infection, and this poison may kill his heart 
muscle cells, in consequence of which the rest of his body cells then die, 
for because the heart has failed no oxygen is supplied the remaining 
tissues of the body. Or, through a rapid loss of carbon dioxid from 
the body, the cells governing respiration in the medulla are no longer 
excited to activity, and so the respiratory movements cease, the blood is no 
longer oxygenated, and the rest of the body cells die because they are 
deprived of oxygen. We could give similar illustrations for the liver, or 
the kidneys, or the thyroid, or any other organ of the body. It is the 
injury to certain cells in each case that furnishes the characteristic signs 
of any pathological entity, and, if this injury or the death of these cells 
removes a condition upon which the life of cells in other parts of the body 
depends, then these, too, die. And so the whole body may die. The 
individual cells of a multicellular organism are like the ordinary ameba, 
only in the complex organism certain functions (possessed also by the 
ameba) have been especially developed and predominantly assumed by 


THE GENERAL CONSTITUTION OF HYING MATTER 5 


groups of these cells. These functions have come to be of particular im¬ 
portance only because they have this character of exercising a function 
upon the proper execution of which the remaining cells of the complex 
body are dependent (respiration, circulation). 

In a complex organism we may, therefore, distinguish between a 
general physiology (common to all cells) and an organ or special physiol¬ 
ogy* When we remember that such organ or special physiology scarcely 
ever represents more than an unusually prominent development of sume 
function of general physiology, the necessity and the predominant im¬ 
portance of the general physiology of the cell become manifest. 

These remarks will serve to show why, in our discussion of certain 
therapeutic principles that are of service in daily practice, we find our¬ 
selves beginning with a discussion of the behavior of the individual cell. 
To he familiar with the effect of various external conditions upon the gen¬ 
eral behavior of the individual cell is to he familiar with the behavior 
of these same conditions upon groups of cells; and if such groups of cells 
(an organ) are part of and determine the behavior of yet other groups 
of cells in a complex organism, to be familiar with the action of these 
external conditions upon the individual cell is to he familiar with their 
action upon the organism as a whole. 

Hence the importance and our interest in the physicochemical consti¬ 
tution of the individual cell. An understanding of the most specialized 
therapeutic procedure is almost invariably dependent upon such a knowl¬ 
edge of the cell. 

So we shall find the behavior of arsphenamine to be but a brilliant 
illustration of the way in which a therapeutic agent distributes itself 
unequally between two cells (spirochsete and body cell) ; the action of the 
cathartic salts but the therapeutic expression of the general effects of 
such salts upon all plant and animal protoplasm. 


THE GENERAL CONSTITUTION OF LIVING MATTER 

The living matter of which all cells are composed needs, from a 
therapeutic standpoint, to be considered from the same viewpoint as its 
physiology, namely, from a purely physicochemical one. Ultimate prin¬ 
ciples of therapy must be physicochemical in character. 

In our special discussion we shall deal hut little with the purely 
chemical aspects of the constitution of living matter. It is enough for us 
to remember that the various chemical constituents of the living cells are 
easily grouped under the general headings of the proteins, the carbohy¬ 
drates, the fats, the salts, and water. But the biological significance of 
the purely chemical attributes of these classes of compounds seems at the 


6 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


present time in our scientific progress to stand largely behind that of 
certain physicochemical characteristics possessed by these same substances, 
and so we find it convenient to regroup these chemical entities under the 
headings of the colloids, the crystalloids, and water. We will consider 
these seriatim, for in a correct understanding of their physicochemical 
behavior are concealed the principles that govern much of our modern 
therapy. 

The Colloids. —The hulk of living matter is made up of colloidal 
material. It will not surprise us, therefore, to discover that the behavior 
of colloidal material is identical with much that we consider characteristic 
of living matter. 

It is now more than fifty years since Thomas Graham recognized 
that different chemical substances differ greatly in the rate with which 
they diffuse through solvents of various kinds. On the basis of this 
observation he made a distinction between those which diffuse slowly and 
those which diffuse very rapidly. As the former are for the most part 
amorphous, and since ordinary glue is an example of this class, he called 
them colloids. The group that diffuses readily he called crystalloids, 
for such beautiful crystalline substances as cane sugar, ordinary salt, and 
urea are found in it. 

Since Graham’s studies, we have become familiar with further char¬ 
acteristics of colloids and crystalloids. Crystalloids are ordinarily stated 
to form true solutions. This colloids do not—they form pseudosolutions, 
that is to say, they simply remain suspended in the solvent. Colloidal 
solutions are, therefore, not homogeneous, but heterogeneous, in their 
make-up. 

Solutions of crystalloids show an osmotic pressure which is propor¬ 
tional to the number of particles of dissolved substance in the unit vol¬ 
ume of the solvent. Upon this fact and the minuteness of the dissolved 
particles depends the diffusibility of the crystalloids. The most typical 
colloids, on the other hand, show practically no osmotic pressure, and 
correspondingly do not diffuse at all. 

The enormous differences in osmotic pressure between crystalloids 
and colloids correspond to similar differences in the molecular weight of 
the substances composing the two groups. The molecular weight of the 
most pronouncedly colloidal bodies may be measured in thousands, while 
two or three hundred covers the weight of crystalloids, even when very 
complex organic compounds are concerned. The table on page 7 taken 
from Rudolf Hober shows this very well. The figures refer to 10 per 
cent solutions of the various substances. 

Crystalloids can, moreover, diffuse uninterruptedly through colloidal 
membranes, such as animal bladders, intestines, sheets of agar-agar or 
gelatin. Colloids are for the most part unable to do this. Upon this 
fact is based the principle of dialysis, in which crystalloids are separated 


THE GENERAL CONSTITUTION OF LIVING MATTER 7 
Colloids and Crystalloids 


Substance 

Molecular Weight 

Osmotic Pressure 
in Atmospheres 

Depression of 
Freezing Point 

Methyl alcohol. 

32 

70.00 

5.781 

Urea. 

60 

37.34 

3.084 

Glucose . 

180 

12.43 

1.027 

Cane sugar. 

342 

6.54 

0.540 

Albumose. 

2,400 

0.93 

0.078 

Albumin . 

13,000 

0.17 

0.015 


from colloids by placing the mixture in a tube of parchment or an ani¬ 
mal bladder and hanging the whole in water or some other solvent. The 
crystalloids diffuse out, leaving the colloids behind. 

It must be stated, at once, however, that between the two extremes of 
the typical colloids, and the typical crystalloids, there is found an in¬ 
finite number of substances which lean more or less strongly toward one 
side or the other. It is possible, for example, to obtain in a crystalline 
form certain albumins which may ordinarily be taken to represent our 
most typical colloids. Egg albumen may be obtained in such a state, and 
the physiological chemist is rarely satisfied with a hemoglobin that is not 
beautifully crystalline. On the other hand, comparatively simple bodies, 
such as silicic or tungstic acid, are found in the group of our most rep¬ 
resentative colloids. These few facts will suffice to show that no hard 
and fast line can be drawn between the colloids on the one hand and the 
crystalloids on the other. 

It should be clearly understood that, while we speak of colloids and 
crystalloids, and therefore are seemingly classifying substances, we ought 
really to speak only of the colloidal and the crystalloidal state. Our 
familiar use of the terms colloidal and crystalloid has grown out of the 
fact that certain chemical compounds are best known to us in the col¬ 
loidal state, while others we see almost always in a crystalloidal state. 
As a matter of fact, it is probably safe to assume that any substance may 
be obtained in a colloidal form, even those simplest and most typical 
crystalloids, the chlorids of the various metals. That many typical 
colloids may, on the other hand, be obtained in crystalline form is evi¬ 
denced almost daily by the ever-growing list of biological products long 
known to us only in the form of amorphous powders, mucilages, and 
syrups which chemists are obtaining in crystalloidal form. These con¬ 
siderations are not without biological significance, for a chemical sub¬ 
stance in a colloidal form may, and usually does, possess entirely different 
properties from the same chemical substance in a crystalloidal form. 
A. A. Noyes distinguishes between those colloids which are viscous, 
gelatinizing, and not readily coagulated by salts and those which are 
non-viscous, non-gelatinizing, and readily coagulated by salts. To the 
















8 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


former of these groups belongs, for example, a solution of gelatin, albu¬ 
min, globulin, glue, or dextrin, while in the latter might be mentioned 
the colloidal solutions of ferric hydroxid, aluminium hydroxid, various 
metallic sulphids, and hemoglobin. Perrin distinguishes between those 
colloids which in the solid state are rich in water and those which 
are poor. The former of these Perrin designates as hydrophilic colloids, 
for the latter the name hydrophobic colloids has been suggested. Eor 
the purposes of biology these terms are excellent, and in large part 
adequate. For the purposes of physical chemistry in general they have 
the drawback of not being sufficiently broad. Water is not the only 
solvent that may form the base of a colloidal solution. To meet this 
objection Herbert Freundlich has proposed the name lyophilic colloids 
for those which show an intimate relationship to their solvent, while 
those which do not do this are called lyophobic. 

Wolfgang Ostwald, who has taken a valuable step forward in the 
proper classification of the various colloids, distinguishes between the 
emulsion colloids and the suspension colloids, the former of which repre¬ 
sent colloidal solutions formed through mixture of two liquid phases, 
the latter through mixture of a solid with a liquid phase. A separation 
of the two phases is difficult to obtain in the emulsion colloids, which 
correspond, it will be seen, with Noyes’s first group and Perrin’s hydro¬ 
philic colloids, while the ready separation of the phases in Ostwald’s sec¬ 
ond group brings to mind Noyes’s second group, and the hydrophobic 
colloids. 

When we recall that the hydrophilic colloids which have thus far been 
accorded most study—gelatin, dextrin, starch, glue, vegetable fibers, al¬ 
bumin, gums—are, for the most part, derived from biological sources, 
their probable importance to the living animal or plant must at once be 
suspected. Not only is the chief mass of the living organism built up 
of colloidal material, but most of it belongs in the hydrophilic group. 
We shall not be surprised in consequence to find that those physicochem¬ 
ical characteristics which make for the division of all colloids into two 
great classes will show themselves of importance in determining the bio¬ 
logical behavior of the tissues. 

Recently, Loeb has contributed to our understanding of the colloidal 
behavior of proteins most valuable and interesting information. He has 
shown that proteins may be looked upon as amphoteric electrolytes, capa¬ 
ble of combining stoichiometrically with acids and alkalis to form salts, 
depending on the hydrogen ion concentration of the protein solution. 
These protein salts are strongly hydrolyzed. In this respect, the chem¬ 
istry of protein does not differ from the chemistry of crystalloids. On 
account of the large size of the protein ion and molecule, diffusion through 
membranes is difficult, while the reverse is true of the small crystalloid 
ions. Donnan has shown that when a membrane separates two solu- 


THE GENERAL CONSTITUTION OF LIVING MATTER 9 


tions, one of which may contain a non-diffusible ion mixed with easily 
diffusible ions, there is an uneven distribution of ions, such that the 
products of the ions on opposite sides are the same. This unequal con¬ 
centration of crystalloid ions on opposite sides of the membrane gives 
rise to potential differences. Loeb has shown that when protein is the 
non-diffusible ion in the presence of easily diffusible crystalloid ions, the 
concentration of the latter is always greater within the protein solution 
than in the surrounding solution, and explains in large measure the col¬ 
loidal behavior of the protein solutions. He has been able to calculate 
with considerable accuracy from Donnan’s equilibrium equation the effects 
of electrolytes on osmotic pressure, swelling and viscosity of proteins. 

The importance of this conception of colloidal behavior cannot he 
overestimated. It suggests new methods of approach to the study of 
such pathological processes as edema, in the hopes that a better under¬ 
standing of the condition may lead to more rational therapy. Use of 
the principles evolved should bring forth most interesting information in 
the fields of physiology, bacteriology and immunology. 

The Crystalloids. —The crystalloids may be divided into two great 
groups, the electrolytes and the non-electrolytes. We shall find that the 
characteristics that make such a division possible in the realm of pure 
physical chemistry also distinguish the biological behavior of these two 
groups from each other. 

Substances which when dissolved in water (and certain other sol¬ 
vents) conduct the electric current are known as electrolytes; those which 
do not do this as non-electrolytes. All the acids, bases, and salts (par¬ 
ticularly the stronger acids, the stronger bases, and the salts formed by 
their union) are electrolytes, while the various sugars, urea, ethyl alco¬ 
hol, glycerin, etc., are familiar non-electrolytes. Pure water (practically) 
does not conduct electricity. Neither will it do this when such a substance 
as dextrose or ethyl alcohol is dissolved in it. But the water conducts 
well as soon as any electrolyte, such as sodium chlorid, is added to it. 

The effects of electricity upon the living body, whether for good or 
ill, are possible only because living matter contains various electrolytes. 
All therapeutic electrical effects are rendered possible because the body 
contains electrolytes. 

The electrolytes behave as they do when dissolved in water because 
in this solvent they are electrolytically dissociated. The atoms and 
groups of atoms that are the product of such dissociation are electrically 
charged (herein differing from the ordinary atoms), and are known as 
ions. Thus, absolutely pure nitric acid (containing no water) does not 
conduct the electric current; nor will it if it is dissolved in some solvent 
that does not lead to an electrolytic dissociation of the acid. This is 
because under these circumstances only the molecules (HNO3) of the 
acid are present. But let water be added to the nitric acid, and this at 


10 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


once dissociates into its two ions (H + and N0 3 "), which carry posi¬ 
tive and negative charges of electricity. In an entirely similar way sul¬ 
phuric acid dissociates into the ions H + and S0 4 "; sodium hydroxid 
into Na + and OH'; sodium chlorid into Na + and Cl". The ions 
which carry a positive electrical charge wander to the cathode, and are 
known as cations; those having a negative charge move in the opposite 
direction, toward the anode, and are known as anions. Thus hydrogen 
is the cation of hydrochloric acid (and of all acids), while chlorin is the 
anion of this same acid (and of all chlorids). 

The degree to which a substance in solution is dissociated differs with 
different substances and varies with the same substance under different 
external conditions. The greatest degree of dissociation is shown by 
the so-called strong acids, bases, and salts, as, for example, hydrochloric, 
sulphuric, and nitric acids; sodium, potassium, and calcium hydroxids; 
sodium chlorid, potassium sulphate, calcium nitrate. But dissociation, 
even for these, is complete only in extremely dilute solutions. The de¬ 
gree of dissociation increases with every rise in temperature. 

For the most part there exist always a certain number of undisso¬ 
ciated molecules beside the ions which are the products of the dissocia¬ 
tion. For the common salts that we find in our bodies, and under the 
conditions prevailing in the body, it is ordinarily held that about 85 
per cent of the salt present is dissociated into ions, while 15 per cent 
remains in the molecular state. This means that, for every one hun¬ 
dred molecules of sodium chlorid, for example, present in the body, fif¬ 
teen are present as such, while the remainder have dissociated to yield 
eighty-five sodium ions and eighty-five chlorin ions. 

It is clear after what has been said that, in dealing with the behavior 
of any substance in solution, this matter of electrolytic dissociation be¬ 
comes of great importance. If we deal with a substance that is incapable 
of dissociating electrolytically, or with one familiarly known to us as an 
electrolyte, but existing at the time under conditions which render dis¬ 
sociation impossible, then it follows that all the effects noted must be 
due to the properties of the molecules present. A non-electrolyte can 
exhibit only molecular effects. This holds whether we deal with its prop¬ 
erties in the form of a simple solution in the chemical laboratory, or 
with its biological behavior as brought to our notice by using this same 
substance as a food or drug (saccharose, glycerin, alcohol). 

In the case of an electrolyte, on the other hand, we have to consider 
not alone the effects of the molecules, but in addition the effects of the 
ions yielded on dissociation, and not the effects of all the ions together, 
but of the individual kinds of ions. So, the effects of sodium chlorid 
become those of molecular sodium chlorid, of the ion sodium, and of the 
ion chlorin. If the degree of dissociation is very small, the ionic effects 
are correspondingly small; if this is great (complete), then the effects of 


SOLUTIONS AND METHODS IN PHARMACOLOGY 11 


the electrolyte may be entirely the sum of the effects of the separate ions 
that are yielded on dissociation. 

Water. —The water found in living matter and in the media sur¬ 
rounding living matter owes its great physiological importance to its 
solvent properties. The various chemical reactions that are characteristic 
of and necessary for the maintenance of life are rendered possible by 
this means, for the solvent properties of water make it possible for the 
dissolved substances to he brought in contact with each other. Water 
dissolves not only solids, such as sugar or salt, hut liquids, such as 
alcohol, or gases, such as oxygen or carbon monoxid. The solutions re¬ 
sulting therefrom still possess many of the ordinary physical properties 
of water, but new ones also appear, which depend upon the quantity and 
the character of the substance dissolved. But the previous state of the 
dissolved substance is of no importance; the resulting solution is the 
same, for example, whether we add to water a certain weight of alcohol 
in the liquid state or in the gaseous state. 

We ordinarily think the water in protoplasm to he like the distilled 
water contained in a test tube in the laboratory. This is largely true, 
but not entirely true. The water contained in living matter has the prop¬ 
erty of dissolving solids, liquids, and gases, as has our ordinary water. 
But the state in which the water is found in the test tube and in living 
matter is not entirely the same. The water found in the body exists 
almost wholly in the form of hydration water; that is to say, the water 
forms a compound with protoplasm. This is true not only of water 
found in cells, hut even of the water found in the blood and in the 
lymph. Uncombined, “free,” water analogous to the distilled water in 
our laboratory test tube is found only temporarily, and in small quan¬ 
tities, in the living animal. As soon as it appears it is excreted. We 
shall see how important is this distinction between hydration and free 
water in the body as we proceed. The maintenance of all secretion de¬ 
pends primarily upon the obtaining of free water, and, as the elimination 
of all poisonous products from the body, whether formed in the normal 
metabolism of the body or introduced from without (arsenic poisoning), 
or manufactured in the body in consequence of the introduction of a 
pathogenic organism into it, is secondary to such a secretion of water, we 
shall see how important these physicochemical facts are from a thera¬ 
peutic standpoint. 


STANDARD SOLUTIONS AND COMPARATIVE METHODS IN 
PHARMACOLOGY 

Owing to the fact that many of the chemical materials used in thera¬ 
peutics represent mixtures of many substances (as, for example, the 


12 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


Various extracts, fluid extracts, and tinctures prepared from plants), ac¬ 
curate quantitative studies on pharmacological behavior have in large 
part been difficult or impossible. Quantitative methods have increased 
hand in hand with advances in chemistry that have given us, in place of 
mixtures, the well-defined chemical bodies that we know as the alkaloids 
and the chemically constant active principles of various plants and or¬ 
gans. Yet, in the comparative study of the behavior of such well-defined 
chemical compounds, to which we can at once add the various acids, aL 
kalis, and salts that form a goodly portion of our therapeutic armamen¬ 
tarium, we have gotten only little beyond the point in which percentage 
solutions of the various compounds are used. In order to make proper 
comparisons between the pharmacological action of various chemical com¬ 
pounds, it is necessary for us to compare amounts that are not simply 
equivalent in weight (as in percentage solutions), but that are equivalent 
from various physicochemical points of view. A definition of a few 
standards used in this regard is therefore in order, for we shall have 
to use these in our further discussion. Comparative studies with solu¬ 
tions of equal percentage are practically worthless, for reasons that will 
appear shortly. 

The gram-molecule is a convenient unit. This is the molecular weight 
of the substance under consideration expressed in grams. A gram-mole¬ 
cule of hydrochloric acid is 35.46 grams; of sodium chlorid, 58.50 grams; 
of ethyl alcohol, 46.05 grams. If the substance contains water of crys¬ 
tallization the molecular weight of this expressed in grams is added to 
that of the substance itself. A gram-molecule of dried sodium car¬ 
bonate (Na 2 C0 3 ) is 106.10 grams, but of the crystalline compound 
(Na 2 CO 3 l 0 lI 2 O) it is 286.26 grams. 

A gram-molecular solution (or a molecular or molar solution) con¬ 
tains a gram-molecule of any substance dissolved in enough water to 
make a liter. If only one-half the gram-molecular weight is dissolved 
in enough water to make a liter we have a one-half molecular solution; if 
one-eiglith the gram-molecular solution is present in the liter, a one-eighth 
molecular solution, etc. Solutions that have the same number of gram- 
molecules of various substances dissolved in the unit volume are equi- 
molecular. 

It is at once apparent that, if the dissolved substances do not undergo 
any change on being dissolved, the same number of dissolved molecules 
are present in all equimolecular solutions. When we employ equimolec- 
ular solutions in pharmacological study we are, therefore, able to com¬ 
pare the behavior of a definite number of the molecules of one substance 
with the behavior of the same number of another substance. 

We can illustrate the advantages of employing such molecular solu¬ 
tions in pharmacological study in place of percentage solutions in the 
following way: It is ordinarily stated that, of the three salts, potassium 


SOLUTIONS AND METHODS IN PHARMACOLOGY 13 


bromid, sodium bromid, and lithium bromid, the last-named acts more 
powerfully than the other two. This is on the basis of equal amounts by 
weight of the three substances being given (say in 10 per cent solutions). 
When we compare the molecular weights of these three substances (which 
stand to each other as 119.11, 103.01, 86.99), the reason for this ap¬ 
parent inequality in action becomes evident. The chief physiological or 
therapeutic effect of these three bromids resides in their bromin content, 
and (roughly) a 12 per cent solution of the potassium salt is required 
to furnish the same amount of bromin as a 10 per cent solution of the 
(anhydrous) sodium salt, or an 8.7 per cent of the lithium salt. Or, 
to apply this to daily practice, when we substitute a gram dose of lithium 
bromid for a gram dose of potassium bromid, we are giving a third more 
of the active constituent of our drug. 

For certain purposes in pharmacological study it is well to employ 
normal solutions. A normal solution is a gram-molecular solution, pro¬ 
vided the dissolved substance is monobasic. In other words, the power 
of the substance to displace hydrogen is taken into consideration. So 
a normal solution of hydrochloric acid contains a gram-molecule (36.46 
grams) of the pure acid in the liter of finished solution. But to get a 
normal solution of the dibasic sulphuric acid, only 49.04 grams, that is 
to say, only one-half the molecular weight (— 98.08), are used; or of the 
tribasic phosphoric acid, only 32.67 grams (=1/3 its molecular weight, 
98.02). Similarly, a normal solution of sodium chlorid (molecular 
weight, 58.5) contains 58.5 grams in the liter of solution, while a normal 
solution of trisodium phosphate (Na 3 P0 4 12H 2 0, molecular weight, 
380.34) contains only 126.78 grams. Clearly, therefore, the familiar 
normal solutions of the chemists are the same as the molecular solutions 
more commonly employed hy the physiologists, 'provided monobasic acids 
or salts are involved. But, if polybasic substances are under considera¬ 
tion, then a normal solution of a dibasic compound has only half the 
concentration of a molecular solution of the same compound; a normal 
solution of a tribasic compound only one-third the concentration of a 
molecular solution of this same substance, etc. 1 

A third basic upon which the solution of various substances must 
at times be standardized is that of their ionic concentration. When the 
electrolytes go into solution in water they become dissociated, as we found 
above. But the degree of dissociation is not the same for all electrolytes, 
and under all conditions. So, for example, if we take a series of equi- 
normal acids, the number of hydrogen ions in these is by no means the 

1 The “physiological salt solution” or “normal salt solution” of our physiological 
laboratories, hospitals, etc., has absolutely nothing to do with the normal solutions 
being discussed here. The terms are misnomers and mean nothing, and should dis¬ 
appear from use. We should speak of an 0.85 per cent or 0.9 per cent sodium chlorid 
solution, if that is what we mean by these terms. 




14 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


same. Strong acids, such as hydrochloric, nitric, or sulphuric, will in 
dilute solution he almost entirely dissociated, but the weak acids, such as 
acetic or carbonic, will he dissociated only very little. Suppose, now, that 
we are trying to determine the relative value of different acids in the 
digestion of the proteins under the influence of pepsin. It is not suffi¬ 
cient under such circumstances to work only with equinormal acid solu¬ 
tions. It is also necessary to work with solutions that have the same 
ionic concentration. For the methods employed in the preparation of such 
solutions the larger textbooks of physical chemistry must be consulted. 


EQUILIBRIUM 

Living matter represents nothing but a series of physicochemical re¬ 
actions of such a nature that the materials necessary for these reactions 
are sought by the living matter (that is, by certain of the physicochem¬ 
ical reactions themselves), while at the same time the products of these 
physicochemical reactions, which if allowed to accumulate would bring 
the whole series to a stop, are properly disposed of, the sum total of re¬ 
actions being accomplished in such a way that the system in which these 
reactions are taking place (living matter itself) undergoes no marked 
changes over long periods of time. What is meant by a long period of 
time is simply a matter of definition; in the case of some of the insects 
it may be but a few hours; in some of the higher animals a century. The 
maintenance of the system constitutes physiology and normal life; every 
interference with it, pathology and disease. The purpose of preventive 
medicine is the maintenance of the former; the purpose of therapy the 
relief of the latter, and its restoration, if possible, to the former. The 
whole is governed by the laws of equilibrium. 

We can best see what all this means in the case of man if we consider 
the ameba. The ameba lives in a state of equilibrium with its surround¬ 
ings. If we take it out of its pond and put it in distilled water it dies. 
If we put it in a strong salt solution it dies, or if we keep it in its own 
pond water, but cover this so that no air can get to the surface of the 
water and into solution in the water, it dies. The grosser reasons for all 
this are easily given. Pond water contains besides water certain salts and 
oxygen. The water in the organism is in equilibrium with the water in 
the pond; the salts in the organism are in equilibrium with the salts in 
the pond water; the oxygen dissolved in the protoplasm is in equilibrium 
with the oxygen dissolved in the pond water. To put the ameba under 
any of the conditions mentioned above is to change one (or indirectly 
several) of these equilibria, and, if any of them is sufficiently changed, 
then that normal system of physicochemical reactions that we call life 


EQUILIBRIUM 


15 


is disturbed, maybe to the point of cessation. In the distilled water the 
ameba loses its salts down to a fatal point; from the concentrated salt 
solution it absorbs more of these than the physicochemical reactions can 
stand; when the entrance of oxygen into the water is rendered impossible, 
then none gets into the living ameba, and so its normal oxidative processes 
are interfered with, and it dies. 

We can, on the other hand, kill our ameba by furnishing it the pond 
water, but by placing it in a position which does not permit it to rid 
itself of the products of its physicochemical reactions. So, if we allow 
the water to get stagnant, it will die. Under these circumstances 
the carbonic acid and other products of its activity accumulate in the 
water about the ameba, and in the ameba itself, and, as the organism 
cannot bear more than a certain concentration of these products, it 
dies. 

The extremes between which our ameba is able still to maintain itself 
(minimal salt concentration, minimal oxygen concentration, maximal car¬ 
bonic acid concentration) are highly important for its life—they con¬ 
stitute the measure of the resistance of the organism to such conditions. 

What has just been said continues to hold true if, without changing 
another word, we write brain cell, or muscle cell, or connective tissue 
cell in place of the term ameba in what we have been discussing. For 
pond water we may substitute the term blood, or lymph; in place of oxy¬ 
gen above the water we may say the air in the lungs; in place of stagnant 
w T ater we may say sweatshop atmosphere. Every cell in the multicellular 
organism is in the same situation as the ameba, and as dependent as this 
upon the liquid medium that surrounds it. If we bear these points in 
mind, the physical chemistry of a therapeutics that urges water, a proper 
salt ration, the out-of-door life, and a ventilated shop system upon us at 
once becomes clear. These are the everyday illustrations of the laws of 
equilibrium that are ordinarily only murmured within the walls of the 
laboratory. 

We shall illustrate this matter of equilibrium a little further: Sup¬ 
pose we have any vessel partially filled with water, and above this any 
gas, such as oxygen. This oxygen will go into solution in the water up 
to a certain point, when no more will be dissolved. If now we increase 
the pressure of oxygen in the space above the water, then more of the 
oxygen goes into solution; or, if we reduce this pressure, some that has 
gone into solution will again escape. The process is, therefore, reversible. 
For any given pressure of the gas there is always a certain amount of 
this gas dissolved in the water. In other words, the dissolved gas is 
always in equilibrium with the gas above it. We represent this as follows: 

Oxygen Oxygen 

(Gas) (Dissolved in the 

water) 


16 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


But let us suppose that a substance capable of combining with the 
oxygen is dissolved in the water. As the dissolved oxygen combines 
with this substance, the concentration of the dissolved oxygen must be 
reduced, and so the previously established equilibrium is destroyed. In 
consequence of this more of the oxygen above the water must now be taken 
up, and this continues until the whole system, in which we now have to 
consider three elements, is once more in equilibrium. In other words: 

Oxygen < > Oxygen .< L Oxygen 

(Above the water) (Dissolved in water) (Combined) 

As a matter of fact, this is exactly what occurs in the blood when it 
passes through the lungs. The oxygen pressure in the alveoli of the lungs 
being higher than that of the oxygen dissolved in venous blood, the oxygen 
passes from the alveoli into the blood. But hemoglobin is found in the 
blood, which is capable of taking up large quantities of oxygen, in con¬ 
sequence of which the equilibrium existing between the oxygen in the air 
and the oxygen dissolved in the blood plasma is broken down in the direc¬ 
tion toward the hemoglobin, and so more oxygen is taken up by the 
plasma. And this continues until an equilibrium exists in the three phases 
involved, thus: 

Oxygen < > Oxygen < Oxygen 

(In alveolar air) (Dissolved in plasma) (Combined with 

hemoglobin) 

When this arterial blood gets to the tissues it meets a region in which 
the oxygen pressure is lower than that in the blood, and so the dissolved 
oxygen in the plasma moves over into the body cells. In consequence of 
this the hemoglobin now gives up its oxygen to the plasma, and this proc¬ 
ess continues until equilibrium is again restored. 

Entirely analogous conditions prevail in the case of carbonic acid, 
and the loss of the carbon dioxid from the lungs. The carbonic acid is 
produced in the cells, and passes over into the blood plasma which passes 
by these cells and in which the concentration of carbonic acid is lower 
than in the body cells. As soon as the carbonic acid gets into the blood 
plasma it begins to combine with the carbonates present and makes 
bicarbonates out of them. The carbonates behave in this regard toward 
carbonic acid as hemoglobin did before toward oxygen. The state of 
equilibrium that tends to become established in the tissues may be rep¬ 
resented as follows: 

RCOa !^±T RC0 3 H2CO3 

(In the cells) (Dissolved in the (In combination with 

plasma) carbonates) 

When the venous blood gets to the lungs, where the C0 2 tension in the 
alveoli is low, the C0 2 of the carbonic acid found in the plasma escapes 






EQUILIBRIUM 


17 


(water remaining behind in the blood). As this happens the bicarbonates 
break down and give lip a part of their carbonic acid to the blood plasma, 
and this continues until equilibrium is again restored. 

Attention may here be directed to the role of the bicarbonates in 
maintaining a constant reaction in the organism. It is well known that 
the reaction (hydrogen ion concentration) of the blood and body fluids 
under normal conditions varies within very narrow limits. In terms 
of the logarithmic symbol suggested by Sorensen, and now used quite 
universally, the pH of the blood in normal subjects seldom becomes more 
alkaline than 7.5, or more acid than 7.3. The pathological variation 
covers a much wider range, pH 7.8 to pH 7.0. When the reaction of 
blood becomes more acid than 7.0, death results in a short time. The 
mechanism by which a very constant reaction (pH) is maintained is 
chiefly due to the bulfer action of the bicarbonates in association with 
carbon dioxid. Plasma proteins, hemoglobin, phosphates, chlorids, free 
oxygen, urea and ammonium salts take part in the buffer mechanism, but 
are of somewhat less importance. In the following discussion, for the 
sake of simplicity, HaHC0 3 will be used to designate the sum of all 
the bicarbonates. In fact, sodium is the chief inorganic base in the body. 

In a solution containing both carbonic acid and sodium bicarbonate, 
the chemical reactions are: 

(1) H 2 C0 3 = H + HC03 

(2) NaHC0 3 = Na + HCOa 

(3) H 2 O = H + OH* 

(4) HCOa = H + COs 

(5) HCOa + H 2 O = H 2 CO 3 + OH 


The equation representing the ionization equilibrium of carbonic acid 
may be written as follows: 

(6) k x [H2CO3] = [H] x [HCOa] 
or 


(7) [H] = k x 


[H2CO3] 

[HCO3] 


In the presence of bicarbonate, there is very little dissociation of the acid, 
so that the concentration of the undissociated molecules may be considered 
to equal approximately the free acid. Furthermore, since salts are largely 
dissociated, the concentration of the bicarbonate ions (HC0 3 ) is ap¬ 
proximately proportional to the total concentration of bicarbonate. Rep¬ 
resenting this proportionality by we may write the equation (7) thus. 



18 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


( 8 ) 


H = - 


a 


X 


H.CO. 

NaHCOs 


It should he clearly appreciated that this expression is an approximation 
only, and is subject to several modifying factors, for a consideration of 
which the reader is referred to textbooks on Physical Chemistry. This 
equation has been extremely useful in the study of many physiological 
and biological problems. 

If we now substitute the values for H — 0.35 X 15' 7 (reaction of 
normal blood), k = 4.4 X 10" 7 and a = 0.6 in equation (8), we have: 


(9) 0.35 x io 7 


4.4 x 10 - 7 v H 2 CO 3 
06 - X NaHCOj 


or 


H*GO. _ 1 
( NaHCOs 21, 


the proportion of free carbonic acid to bicarbonate in the blood. In order 
to appreciate the effectiveness of the buffer value of the bicarbonates 
alone in the blood, we may calculate the amount of one-tenth normal 
acid solution required to change the ratio in a 70-kilo man from 1/21 
to 2/21 and determine the effect from equation (8). It may he assumed 
for purposes of illustration that the concentration of bicarbonates through¬ 
out the body fluids is quite uniform, also that 70 per cent of the body 
weight is water. The concentration of bicarbonate in the normal subject 
is approximately 0.03 molar. 

There are then in our 70-kilo man about 49 liters of 0.03 normal 
carbonic acid—bicarbonate solution in the ratio of 1 of acid to 21 of 
alkali. By adding a liter of one-tenth normal acid to the above mixture, 
the ratio would be changed to approximately 2/21. The effect on the 
reaction of the blood may be determined by substitution in equation (8) : 


i?= 0 - 7X10 - 7 


That is, in spite of the large amount of acid added to the solution, the 
reaction (hydrogen ion concentration) of the blood has been changed from 

0.35 x 10- 7 to 0.70 x 10- 7 


which is still within the limits compatible with life. 

The importance of the above-described equilibrium can scarcely he 
overestimated. The ease and regularity with which the respiratory 
mechanism eliminates C0 2 provides a very wide margin of safety in 
keeping the reaction of body fluids within safe limits. Even under the 
stress of abnormal metab(? 7 ’sm, such as is encountered in diabetic acidosis, 







EQUILIBRIUM 


10 


the reaction of the blood is maintained within normal limits, although the 
total bicarbonates may be depleted to within one-fifth its normal concen¬ 
tration. The importance of a clear understanding of regulation of the 
acid base equilibrium within the organism becomes apparent in the 
treatment of acidosis (see chapter on Acidosis). 

A classical example of purely chemical equilibrium is furnished by 
the combination of ethyl alcohol with acetic acid. If at a definite tem¬ 
perature chemically equivalent amounts of acetic acid and ethyl alcohol 
are mixed together, a reaction ensues according to the following equation, 

CHaCOOH + C2H5OH = CHaCOOCaHa + H2O 
(acetic acid) (ethyl alcohol) (ethyl acetate) (water) 

The reaction takes place in the direction from left to right. If, now, 
we mix together chemically equivalent amounts of ethyl acetate and water, 
ethyl alcohol and acetic acid are formed. In other words, the above re¬ 
action takes place from right to left. Neither in the first nor in the second 
instance does the reaction become complete. Before the given amounts 
of acetic acid and ethyl alcohol, or ethyl acetate and water, have under¬ 
gone complete decomposition, the reaction comes to a standstill. Such 
a reaction which can take place from right to left as well as from left to 
right is called a reversible reaction. We indicate this as we have done 
above in the case of oxygen and carbonic acid as follows: 

CHaCOOH + C2H5OH CILCOOCJL + H2O 

It can be readily seen that, when equilibrium is established in a re¬ 
versible reaction, the four substances reacting with each other are present 
in the reaction mixture. The characteristic feature of such a condition 
of equilibrium is found in the fact that under the same external condi¬ 
tions it is always the same, no matter from which side it is reached. In 
other words, it is immaterial whether chemically equivalent amounts of 
acetic acid and ethyl alcohol or chemically equivalent amounts of ethyl 
acetate and water are mixed together. The condition of equilibrium is 
in the end the same in either case. 

Although we say ordinarily that when equilibrium has been estab¬ 
lished the reaction has come to a standstill, this is really incorrect. When 
equilibrium has been established between the two sides of an equation 
it really means that the chemical changes are still going on, only the 
amount of change in the one direction is exactly counterbalanced by the 
reverse change in the opposite direction. The reaction is, therefore, 
stationary. 

What happens if after equilibrium has been established we introduce 
into the reaction mixture either ethyl acetate or acetic acid and alcohol, 
or remove either of these from the amounts that are present? Clearly 




20 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


this must disturb the existing equilibrium, and, depending upon the side 
upon which this disturbance has taken place, more ethyl acetate and water 
must be formed, or more ethyl alcohol and acetic acid. 

Upon the operation of these laws of equilibrium depend not only all 
the processes of normal absorption and secretion by the living animal, but 
all those of abnormal absorption and secretion that are better known to 
us under the headings of intoxication , and its reverse, detoxication . How 
to prevent the former, and how to aid the latter, constitute two cardinal 
problems in therapy. 


DIFFUSION 

If we very carefully pour some distilled water upon a concentrated 
solution of copper sulphate, the colored layer does not immediately mix 
with the clear water above it. If we set the apparatus aside in a quiet 
place and watch it, we notice that the blue color gradually spreads up¬ 
ward through the clear water until in the end the whole vessel contains 
a uniformly blue solution. The dissolved particles of copper sulphate 
spread upward into the clear water by a process of diffusion. 

To return once more to our ameba in its pond water (which we have 
made analogous to the individual cells composing man surrounded by 
their blood and lymph), we can say that all the substances necessary for 
the life of this ameba, or the various poisons that may be added to the 
pond water to injure or kill the ameba, get from the pond water into 
the organism by a similar process of diffusion. Conversely, the poisonous 
products formed by the ameba in its daily life, or the substances which 
have accidentally found their way into the organism and are capable of 
acting as poisons, can get out of the ameba into the surrounding medium 
(and so he swept away) only through this same property of diffusion. 

We have already discussed how important a part the laws of equilib¬ 
rium play in this process of diffusion. Diffusion is possible only because 
the distribution of the dissolved substances in the system under discussion 
is not of such a character as to have the whole in equilibrium. Food 
substances, oxygen, and poisons diffuse into the living ameba because the 
concentration of these within the ameba is less than that necessary to 
establish an equilibrium between the substances as found here and the 
same substances found in the pond water. Similarly, the various poison¬ 
ous products and many of the normal constituents of protoplasm, notably 
the salts, diffuse out because the concentration of these in the pond water 
is less than sufficient to be in equilibrium with these same substances as 
found in the protoplasm of the ameba. Upon the maintenance of a proper 
concentration of food supply, medicinal agent, or poison in the pond 
water (or blood and lymph) depend in the first instance proper nutrition 


DIFFUSION 


21 


and adequate therapy, or an intoxication. Upon the maintenance of a 
sufficiently low concentration of the involved substances in the second 
case (circulation of fresh water about the ameba, administration of water 
to a poisoned man) depends the removal of the poisonous substances 
from the intoxicated cell, while there resides in this good therapeutic 
procedure the danger at the same time of injuring the involved cells by 
allowing the diffusion out of them of some of their normal constituents. 

We have now to consider some of the factors that modify the problem 
of diffusion as this operates in the living animal. Thus far we have en¬ 
tirely ignored the time factor, and, secondly, the fact that living cells are 
more than mere isolated drops of water. In other words, the nature of 
the diffusing substances and the constitution of protoplasm affect this 
process of diffusion as originally described in our cylinder of water, at 
the bottom of which we had placed a concentrated copper sulphate solution. 

We have already touched upon one great classification of the various 
substances that are concerned in the physiological and therapeutic aspects 
of this problem of diffusion. The state in which a chemical compound 
exists affects its diffusion behavior. The colloids we noted above scarcely 
diffuse at all when compared with the way in which crystalloids diffuse. 
Herein, for example, resides one of the great purposes of digestion. 
Through digestion the colloid proteins, carbohydrates, and fats are 
changed into compounds that are crystalloidal in character, and so from 
a state in which they practically cannot diffuse into living cells to one in 
which they do this promptly. 

But even among the crystalloids the rate at which diffusion occurs 
is by no means the same. The diffusion velocity of sodium chlorid, dex¬ 
trose, and magnesium sulphate decreases in the order named. Similarly, 
the rate of diffusion of these substances into cells (their absorption) 
decreases in the order named. 

Along with these specific differences in the rate of diffusion of differ¬ 
ent dissolved substances we have to remember that, if we are dealing with 
a mixture of diffusing substances, the one may modify the rate of diffusion 
of the other, as this would have appeared had it alone been in solution 
(Arrhenius). 

Another factor that influences this problem of diffusion as observed 
in living matter resides in the fact that protoplasm is not a pure solvent 
(water), hut a colloidal mass. It used to he held that diffusion occurs 
just as readily into and through such a colloidal mass as gelatin or agar- 
agar as into and through pure water, but this is not strictly true. The 
presence of colloidal material retards the rate of diffusion of dissolved 
substances, and this the more the higher the concentration of the colloid 
in the medium into which diffusion is occurring. Or, to apply this to 
the problem of pharmacology, a dissolved substance will enter the pro¬ 
tein portions of a cell less rapidly than pure water; or, if different cells 


22 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


are involved, it will enter most rapidly into those which are richest in 
water. Now, since the water capacity of any tissue cell varies under 
physiological and pathological conditions (normal water content and 
edematous state), it is evident that corresponding herewith substances 
may diffuse into cells more rapidly at one time (say in certain diseases) 
than at another. 


DISTRIBUTION 

Thus far our argument has shown us that diffusion occurs from a 
region of higher concentration to one of a lower concentration, and has 
seemed to indicate that this will go on until the concentration of each 
of the diffusing substances is the same everywhere. In other words, it 
has seemed as though the attainment of a state of equilibrium is synony¬ 
mous with equality of distribution. 

So, for example, in our ameba we have made it appear that equilib¬ 
rium would be established between the ameba and the pond water sur¬ 
rounding it as soon as the concentration of every dissolved substance in 
the two phases is the same. The same would hold true of the individual 
cells of the multicellular organism. So we might suppose that after a 
dose of potassium iodid or strychnin or alcohol to a patient, equilibrium 
would be attained as soon as the distribution of these various drugs was 
the same in all the tissues and fluids of the body. 

Actually we know that nothing of the sort occurs. In fact, we know 
that a uniform distribution of any dissolved substance throughout the 
cells and fluids of a living organism probably never occurs. So the con¬ 
centration of the various salts in the ameba is not that of these same 
salts in the pond water; and the potassium iodid, the strychnin, and the 
alcohol distribute themselves very unequally through the multicellular 
organism. The iodids are likely to accumulate in the thyroid; the strych¬ 
nin in the spinal cord; the alcohol in the brain. These inequalities in 
distribution are pointed to by men who believe that we shall never be 
able to interpret all life phenomena on a purely physicochemical basis 
as evidences indicating that living matter has “peculiar” properties not 
known to the physical chemist in his study of “dead” material. Such 
pessimism is at least premature. As the following shows, we are already 
in a position that permits us to account very easily for a large bulk of 
these phenomena. 

Causes of Inequalities in Distribution 

Inequalities in Solubility. —When we take a solution of iodin in 
water and cover this with a little ether and shake the whole, we can see 
even from naked eye appearances that the iodin is ultimately present in 


DISTRIBUTION" 


23 


very unequal concentrations in the two liquids. While scarcely any color 
remains in the water, the ether shows a deep coloration with iodin. The 
process is a homely illustration of the everyday chemical procedure 
that we call “shaking out with an immiscible liquid.” The extraction 
of the iodin from the water by the ether depends upon the fact that iodin 
is soluble in the ether, and, in the example cited, the solubility of the iodin 
is so decidedly greater in the ether than in the water that practically all the 
iodin moves over into the ether phase. The ultimate state of equilibrium 
attained, which is characterized by this very unequal partition (distribu¬ 
tion) of the dissolved substance between the water phase and the ether 
phase, is in this case due to the difference in the relative solubilities of the 
iodin in the water and in the ether. As the iodin is more soluble in ether 
than in water, most is ultimately found in the ether phase. If we take 
equal volumes of water and ether, and drop into the mixture a measured 
amount of iodin, say a gram, we find, when equilibrium has been attained, 
that (roughly) one-tenth of this has dissolved in the water and nine-tenths 
in the ether. If we use instead 2 grams of iodin, we have again the 
same proportionate distribution of the iodin, one-tenth of the amount 
added goes into the water, and nine-tenths goes into the ether. And this 
result is constant, no matter whether we first mix the water and the ether 
and then add the iodin, and whether we dissolve the iodin in the ether and 
then add the water, or vice versa. In the end the state of equilibrium 
attained is always the same* The proportion of iodin dissolved in each of 
the two phases—in this case a concentration of iodin nine times as high 
in the one as in the other—is always constant. We call this the distribu : 
tion coefficient or coefficient of partition. 

In our discussion of the living cell so far we have spoken of its solvent 
powers for various substances chiefly from the standpoint of its water 
content. If the cell had solvent powers only so far as its water content 
is concerned, it is obvious that dissolved substances could never appear 
in it in higher concentrations than those of these substances in the media 
surrounding the cell. But this conception of the cell is too limited. In 
addition to water, the various cells of all living organisms contain fat 
and fatlike bodies. The latter are called lipoids, and include such sub¬ 
stances as cholesterin, lecithin, protagon, and cerebrin. We can see in 
advance, therefore, that the living cell must be able to take up (that is, 
dissolve or absorb) many substances that are better soluble in such 
fats and lipoids than in water, in greater amounts than the media 
surrounding these cells which are less rich in, or devoid of, these sub¬ 
stances. 

We are indebted to Hans Meyer and to E. Overton for recognizing 
the great physiological and pharmacological importance of the facts here 
outlined. (The distribution law of Berthelot and Jungfleisch.) By 
methods which we need not discuss here, these authors found it pos- 


24 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


sible to differentiate between substances which pass into or through cells 
very slowly, and those which pass rapidly. 

To the compounds which diffuse rapidly into protoplasm belong the 
monatomic alcohols, aldehyds, and ketones, the hydrocarbons with one, 
two, and three chlorin atoms, the nitro-alkyls, the alkylcyanids, the neu¬ 
tral esters of inorganic and many organic acids, anilin, etc. The diatomic 
alcohols and the amids of monatomic acids pass into cells more slowly; 
and still more slowly glycerin, urea, and erythrite. The hexatomic al¬ 
cohols, the sugars with six carbon atoms (hexoses), the amino-acids, and 
the neutral salts of the organic acids diffuse into cells only very slowly 
(Overton). 

A simple glance at the list just given shows that we have to deal here 
with all manner of chemical substances. Some of these are relatively 
simple in composition, some very complex; some are of physiological im¬ 
portance, and are found as normal constituents of the living cell; others 
are entirely foreign to the living organism. What physicochemical char¬ 
acter have all these substances in common, which allows them to penetrate 
living cells with more than usual ease, and so to stand out from the great 
group of the ordinary neutral salts, for example, which can penetrate 
the cells only much more slowly? 

An explanation frequently given and long believed to be the correct 
one is that the size of the molecules is the condition which determines 
the entrance of the dissolved particles. According to this conception, the 
cell protoplasm as a whole, or the “membranes” (to be discussed later) 
believed by many (including Overton) to exist about cells, are regarded 
as sieves which allow all molecules that do not exceed a certain size to 
pass into the cell, while those larger than this are held back. The de¬ 
ficiencies of any explanation which calls for the existence of membranes 
about cells we will point out later, but even now it must be apparent 
that the sievelike behavior attributed by some authors to such mem¬ 
branes or to protoplasm as a whole lacks all support, for cells which 
readily give passage to such large atomic aggregates as the alkaloids and 
sodium salicylate hold back the much simpler amino-acids and potassium 
sulphate. 

The substances enumerated above enter cells because the cells con¬ 
tain substances which in their properties as solvents behave not unlike 
ether. All those compounds which are more soluble in ether (and other 
oil-like bodies) than in water must, therefore, pass into and through 
cells containing etherlike solvents (fat, cholesterin, lecithin, cerebrin, 
protagon), more rapidly than into and through such as do not contain 
such solvents; and with a given cell the rapidity and the absolute amount 
of any compound ultimately taken up must depend upon the relative 
degrees of solubility of the substance concerned in water and in the ether¬ 
like bodies contained in the cells (distribution coefficient). In other 


DISTRIBUTION 


25 


words, it depends upon the distribution coefficient of the dissolved sub¬ 
stance between the two phases (water and etherlike bodies) whether 
any dissolved substance will enter a cell slowly or rapidly, and whether 
it will ultimately be found in the cell in a greater, in the same, or in 
a lower concentration than in the medium surrounding it. 

With these ideas in mind, it is only necessary to reexamine the list 
of substances which experiment has shown enter cells with more than 
usual velocity, and see if they are not all of them of a character which 
renders them more soluble in ethereal or oily substances than in water, 
and if those which stand first in the list and consequently enter cells most 
rapidly are not such as have the highest distribution coefficients in favor 
of the ethereal or oily substances. An illustration or two may make this 
clearer. The repeated substitution of an atom or a group of atoms for 
some other atom or group of atoms in a chemical compound is often 
accompanied by marked changes in the solubility of the compound and 
its derivatives. Glycerin enters a cell only very slowly. When an atom 
of chlorin is introduced into this compound, the new compound obtained 
enters protoplasm more rapidly, and, when two are introduced, still 
more rapidly, for these derivatives are more readily soluble in fats than 
the original glycerin. The same holds true of urea and its methylated 
derivatives. While urea diffuses hut slowly into cells, the introduction 
of one, two, or three methyl radicals into this compound increases progres¬ 
sively its solubility in fats, and also the rate of diffusion into living cells. 

The tremendous pharmacological importance of these simple facts is 
self-evident. In order that a substance may produce any physiological 
effect, it must first get into the cell. Other things being equal, we may 
therefore expect a quicker and a more powerful effect from a lipoid- 
soluble pharmacological preparation than from one that is not thus 
soluble. Upon this depends a whole chapter in the chemistry of pharma¬ 
cological preparations, in which some pharmacologically active compound, 
which in itself gets into cells only slowly and so is not very active, is 
made active by being introduced into some compound which is more 
readily soluble in the lipoids. 

The marked effect of all the anesthetics (chloroform, ether, alcohol, 
ethyl chlorid), and the various alkaloids (morphin, cocain, atropin), is 
associated with the fact that they are lipoid-soluble. Their great effects 
upon the central nervous system are in large measure associated with 
the fact that nervous tissues are rich in fat and fatlike bodies, and so 
these tissues take up these substances with special avidity. We can 
appreciate also why a fat individual demands more anesthetic before 
going to sleep than does a lean one. Anesthesia, like all intoxication, is 
a matter not of absolute amount present, but of concentration. The 
various grades of anesthesia go hand in hand with definite concentrations 
of anesthetic in certain cells of the central nervous system. It must 


26 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


evidently take longer to attain this concentration in a fat man than in a 
lean one, for the ready solubility of the anesthetics in fat means that the 
ordinary fat-containing cells of the body must be saturated with anesthetic 
at the same time that we are trying to do this to certain cells in the cen¬ 
tral nervous system. And so a greater initial absolute amount of anes¬ 
thetic must be taken up by a fat individual than by a leaner one. 

Inequalities in Distribution Due to Inequalities in Adsorption. —Not 
only may a living cell come to contain in the unit volume a greater amount 
of a dissolved substance than does the surrounding medium because the 
cell contains better solvents for the dissolved substance than does the 
surrounding medium, but it may take up an unexpectedly large amount 
because of its adsorptive powers. These adsorptive powers are associated 
with the fact that the cell is largely colloidal in its make-up. The general 
problem of adsorption may be illustrated as follows: 

If we dissolve a dye in distilled water, we get a uniformly colored 
solution. If, now, we divide the solution into two parts, and add to the 
one a little finely powdered charcoal and then shake both, we find after 
a little time that, while our control solution remains entirely unaltered, 
the color has very largely disappeared from the other. We are not deal¬ 
ing here with a chemical reaction; the pure carbon that we added to 
the colored solution does not react chemically with any of the constitu¬ 
ents in the tube. The powdered charcoal has a great surface, and the 
action of this great surface upon the dissolved particles of the dye has 
made this accumulate (condense) upon the surface of the charcoal. The 
theory of how this surface action is accomplished need not interest us 
here. 

What has been described is an example of adsorption. The charcoal 
used in the experiment is the adsorbent; the dye the adsorbed substance. 

An enormous number of substances could be cited as acting under 
various conditions as such adsorbents; and almost any substance could be 
given as an example of a material capable of being adsorbed. Kaolin, 
finely divided precipitates of all kinds, or any of the inorganic or organic 
colloids may take the place of carbon in the above experiment, and acids, 
alkalis, and salts can be adsorbed in the same way as our readily vis¬ 
ible dye. Examples of adsorption are familiar to every one. The chem¬ 
ical decolorization of beers, sugars, etc., ujider the influence of animal 
charcoal; the removal of color from a bath by dipping wool, cotton, etc., 
into it (dyeing) ; the staining of histological specimens, are all examples 
of adsorption. 

The adsorption of any substance by an adsorbing agent is never com¬ 
plete. In the case of a dye and charcoal, it is never possible to take all 
of the dye out of the bath with the charcoal; a little always remains 
behind. In other words, the distribution of the dye between the solvent 
and the adsorbent is governed by the laws of equilibrium. If, after we 


DISTRIBUTION 


27 


have had the charcoal take as much of the dye out of the solution as is 
possible, we pour off the supernatant liquid and substitute pure water 
for it, then some of the dye will leave the charcoal and go back into solu¬ 
tion in the water. In this way we can again wash all the dye out of the 
charcoal. Conversely, if, after we have had the charcoal take up as 
much dye as possible, we add more dye to the supernatant liquid, then 
the charcoal will proceed to take up an additional amount from that 
which we have added. 

The relationship between the concentration of the substance to be 
adsorbed and the amount taken up by the charcoal is an interesting one, 
and may be thus stated: From relatively dilute solutions the adsorbent 
will take up much, from more concentrated solutions relatively less, of 
the substance to be adsorbed. In other words, if at a certain concentra¬ 
tion we can take four-fifths of the dye present in a solution out of this 
with a given amount of charcoal, then, if the dye has a higher concentra¬ 
tion, we can take out only less than four-fifths, or, if it has a lower con¬ 
centration, more than four-fifths. 

Protoplasm behaves toward substances dissolved in a medium that- 
surrounds it in an entirely similar way. This constitutes another reason 
why protoplasm may contain the same, a higher, or a lower concentra¬ 
tion of any dissolved substance than the medium surrounding it. The 
protoplasm (adsorbent) of different cells behaves differently toward the 
same external conditions, and so it comes to pass that, while all cells 
are bathed with essentially the same blood and the same lymph, they do 
not all adsorb the same amount of the proffered materials. In other 
words, equilibrium is not attained between the protoplasm of different 
cells and the medium surrounding these, at exactly the same point. 
Hence it happens that the salt content of different cells is not only not 
the same under physiological conditions, but, if we offer the cells of the 
body any pharmacological preparations (say an iodid), all the cells of 
the body will not take this up equally. So the thyroid, for example, 
because of its peculiarly high adsorbent powers for the iodids, will be 
found particularly rich in iodin after medication with this drug; iron 
will tend to collect in the liver and the mammary glands, etc. 

The adsorption properties of protoplasm are markedly influenced by 
various external conditions. If we alter the reaction of the medium 
in which protoplasm finds itself (say from the normally neutral to an 
acid one), then the adsorption powers change most markedly. Thus a 
given tissue which under normal circumstances proved an excellent ad¬ 
sorbent for certain dissolved substances may practically lose this, or 
conversely, a tissue which before adsorbed a given substance only poorly 
may now take this up with avidity. The pharmacological import of this 
is easily seen. The former is equivalent to a defective adsorption, the 
second to an abnormally good adsorption. The maintenance of a normal 


28 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


physiology (absorption of food) depends npon the former, or the proper 
absorption of a pharmacological preparation. Loss of adsorption power 
may, therefore, be followed by serious consequences. On the other hand, an 
increased adsorption power may be equally dangerous, for a pharmaco¬ 
logical preparation which is absorbed but little by a given healthy tissue 
may in disease be absorbed so well that it produces unexpectedly powerful 
effects. 

Specific Chemical Differences. —A third reason why a cell may con¬ 
tain substances in a higher (or lower) concentration than the medium 
surrounding the cell resides in the fact that the cell may contain sub¬ 
stances capable of combining chemically with the proffered dissolved sub¬ 
stance. So, for example, if a cell contains iron, it is reasonable to expect 
in advance that this cell will take up more of a proffered poison capable 
of combining with the iron (say a ferrocyanid) than a cell not containing 
iron, or iron in less amount. We need not multiply such illustrations, for 
the list is as long as the list of chemical reactions capable of ensuing 
between the various substances found in any living cell and the sub¬ 
stances that come normally or abnormally in contact with this cell. 

All the “specific” effects of various pharmacological preparations of 
“toxins,” or “ferments,” etc., and the “specific reactions” of protoplasm 
due to these, are generally regarded and might be used in illustration 
of such inequalities in distribution as we are here discussing. This 
point of view is, in the main, correct. But it is likely to be carried too 
far. We are still too strongly under the influence of the “purely chem¬ 
ical” point of view in this matter. We have already learned that many 
of the “specific immune reactions” are not so intensely “specific,” and 
the whole realm of colloid chemistry is dotted with examples of reactions 
that have been looked upon as “chemical” in character when further 
analysis has shown that what was considered “specific” in these reactions 
did not depend upon the presence of certain chemical compounds, but 
rather upon the physical states in which the components of the reactions 
entered into these. 

Interference from “Membranes.” —Were we to sum up in a few words 
our conception of the structure of protoplasm as thus far developed, we 
could liken it fairly accurately to a mass of gelatin (protein) intimately 
mixed with more or less fatlike material (the fats and lipoids), the 
whole being under physiological conditions immersed in a liquid (pond 
water in the case of our ameba, or lymph and blood in the case of our 
body cells), from which the protein-fat mixture soaks up a certain amount 
of water as well as the various dissolved substances found in this water. 
What governs the matter of water absorption we shall have occasion to 
discuss shortly. The absorption of the dissolved substances we have made 
a matter of equilibrium between the medium outside the cell and the 
medium which constitutes the cell, and we have indicated how the solu- 


IMPORTANCE OF ELECTROLYTIC DISSOCIATION 29 

bility characteristics, the phenomena of adsorption and chemical com¬ 
bination, influence the point at which equilibrium is reached. This simple 
picture of the cell furnishes to our minds an adequate conception of its 
main structure. 

But this is not the conception of the cell which all, or even the ma¬ 
jority, of biological workers accept as correct. Since the studies of W. 
Pfeffer and Hugo de Vries it has been generally held that both plant 
and animal cells have “membranes” (osmotic membranes or semiperme- 
able membranes) about them. This is a teaching which we believe in¬ 
correct. The question is discussed in greater detail later, but it is brought 
up here because, if such membranes existed about cells, they would be 
an additional factor in determining the distribution of dissolved sub¬ 
stances between cells and their liquid surroundings. 

The original teachings of Pfeffer and De Vries held the membranes 
about cells to be entirely analogous to the osmotic membranes (the so- 
called semipermeable precipitation membranes) of the physical chem¬ 
ists. Such membranes are freely permeable to the solvent (water), but 
impermeable to substances dissolved in the solvent. Did such membranes 
exist about cells, it is therefore clear that water could freely pass into 
and out of cells, but the substances dissolved in the water surrounding 
the cells could not get in, and those in solution within the cell could 
not get out. 

On the face of things, it is evident that such a conception cannot be 
wholly correct, for, if cells had true semipermeable membranes about 
them, no food materials could ever get into them, no products of metab¬ 
olism get out, and this would mean death. So, for these true semiper¬ 
meable membranes the more modern school has substituted such as are 
partially permeable, and very complicated these are. As we do not- 
think that any such complicated structures exist, we shall not discuss 
them further. We only wish to emphasize the fact that, should such 
membranes ultimately be shown to exist about cells, they will be capable 
of maintaining concentration differences (at least for shorter periods of 
time) between the dissolved substances within the cell and those with¬ 
out, for, if a membrane is permeable only to some dissolved substances, 
then those which cannot , pass through may accumulate in unusual quan¬ 
tities either within or without the cell. 


PHARMACOLOGICAL IMPORTANCE OF THEORY OF ELECTRO¬ 
LYTIC DISSOCIATION 

In the earlier portions of this chapter it was found that the crystal¬ 
loids can be divided into two great groups, the electrolytes and the non¬ 
electrolytes. When the electrolytes go into solution in water we find 


30 SOME PHYSICOCHEMICAL PEINCIPLES IN THEKAPY 


them to undergo dissociation, so that ions result. When we deal with 
the effect upon protoplasm of various electrolytes dissolved in water, do 
we deal with effects of the molecules of these electrolytes, or with 
the effects .of the various ions which these yield on solution ? So far as 
the pure chemistry of the electrolytes is concerned, we know that their 
behavior is determined, in the main, by the ions they yield on solution. 
So, for example, the various group reactions that we are familiar with 
in chemistry are now known to be essentially reactions between ions of 
the same kind. The reason that all acids taste sour, redden litmus, and 
attack metals is that on solution in w^ater all acids yield hydrogen ions— 
the property that all acids have in common. Alkalis, on the other hand, 
have an alkaline taste, turn litmus blue, etc., because all have hydroxyl 
ions in common. 

The specific differences between different acids arise from the fact 
that the radicals united with the hydrogen in the molecular acids are 
different, and when dissolved in water these form different kinds of ions. 
So hydrochloric acid and nitric acid, when dissolved in water, are the 
same in that both yield hydrogen ions, but different in that the one yields 
chlorin ions in addition, while the other yields N0 3 ions. Similarly, the 
specific differences between the bases are to be sought in the specific 
differences between the metals with which the hydroxyl in the base is 
combined. On solution in water the bases are all the same in that they 
yield hydroxyl ions, but different in that sodium hydroxid yields in 
addition sodium ions, potassium hydroxid potassium ions, and calcium 
hydroxid calcium ions. 

When silver nitrate is added to a mixture of different salts, all the 
chlorids are precipitated. This is because all the chlorids on solution 
in water yield chlorin ions, and the silver ions of the silver nitrate re¬ 
act with these and produce a precipitate. When silver nitrate is added 
to a substance in solution which contains chlorin, but not in a form 
which makes this appear as chlorin ions, no such precipitate is formed. 
Thus silver nitrate does not precipitate the chlorin from a chlorate, for this 
does not yield Cl ions as does the chlorid, but C10 3 ions; nor the chlorin out 
of chloroform which is a non-electrolyte, and therefore yields no ions at all. 

When we deal with the effects of the various acids, bases, and salts 
upon protoplasm, in other words, with the effects of these various elec¬ 
trolytes, do we deal with the effects of the various molecules of these 
compounds or with the effects of the various ions that these yield in 
solution? In greater part we deal with the effects of the various ions 
that these yield. 

The first proof of the truth of this statement was brought by H. 
Dreser, and in the field of pharmacology. Dreser was working with the 
effects of different mercury salts, and showed that their toxic action 
was primarily a function of the mercury ions they yield on solution in 


IMPORTANCE OF ELECTROLYTIC DISSOCIATION 31 

water. When the toxic effect of solutions of different mercury compounds 
containing the same amount of mercury in the unit volume are com¬ 
pared, it is found that, in spite of this fact, they have a very different 
degree of toxicity. Thus mercury sulphocyanate is more toxic than mer¬ 
cury cyanid, and this more toxic than mercury thiosulphate. While 
all these compounds yield mercury ions when dissolved in water, they 
yield an unequally great number. Corresponding to the fact that the 
first yields the largest number, it is found to be most toxic. 

The next evidence in this direction was brought by Griitzner, who 
showed that the toxic effect of various acids on nerves was chiefly a 
function of the hydrogen ions the acids yield, and that the degree of 
toxicity of different acids parallels (roughly) the degree of dissociation 
of the acids; in other words, the concentration of the hydrogen ions. 
Kahlenberg and True brought out the same fact in studying the effect 
of various acids, bases, and salts on the growth of sprouting beans. These 
authors found that such sprouting beans will just live in solutions of 
the strong acids (HBr, HC1, HN0 3 , H 2 S0 4 ) when a gram-molecule of 
these substances is dissolved in 6,400 liters of water. In solutions as 
dilute as this, dissociation into ions is complete, and there are no longer 
present any molecules of the acid. Hence, the toxic action cannot be due 
to the molecules of acid. The toxic action can therefore be due only to 
the hydrogen ions, or to the different acid ions, or to these together. No 
toxic effect is shown by a sodium chlorid solution, which is equimolecular 
with a toxic hydrochloric acid solution, and, since such a sodium chlorid 
solution yields just as many chlorin ions as the acid solution, the toxic 
effect of the acid solution cannot be due to the chlorin ions. It must, 
therefore, be due to the hydrogen ions. 

By similar methods it can be shown that the toxic effect of hydroxids 
is chiefly a function of their hydroxyl ions. Sodium chlorid solutions 
having a concentration equivalent to toxic sodium hydroxid solutions are 
non-poisonous. Since both contain sodium ions and in the same con¬ 
centration, and since the hydroxid solution is toxic at a concentration 
when dissociation is complete, the toxic effect of the sodium hydroxid 
must be due to the hydroxyl ions. 

In the same way J. Loeb has shown that the loss of irritability of 
a muscle and the amount of water this absorbs in an acid solution is 
a function of the ions of the acid concerned; Richards has shown that 
the taste of acids, alkalis, and salts is dependent upon the ions they yield; 
Kahlenberg and True, Paul and Kronig, and Scheurlen and Spiro, that 
the antiseptic action of various metallic salts (mercury, silver, gold) is 
determined in the main by the ions they yield, and is the greater the higher 
the number of poisonous ions yielded. 

Since these earlier papers an enormous literature has sprung up 
around this general subject of the physiological effects of ions. 


32 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


EFFECT OF VARIOUS EXTERNAL CONDITIONS ON 
COLLOIDAL STATE 

Our discussion thus far has brought us to a realization of the fact 
that the reactions which characterize the living cell occur in a colloidal 
medium; it has further indicated the means by which various dissolved 
substances get into and out of this colloidal substance. We have now 
to discuss the relation of these two to each other; in other words, the 
action of the various substances which manage to get into or are produced 
in and fail to get out of a cell upon this colloidal matrix and, conversely, 
the effect of the matrix upon the substances dissolved in it. 

We can sum up the problem involved from our special viewpoint by 
discussing the effect of various external conditions upon the physical state 
of colloidal material. What is said under this heading may then with 
slight or no modification be directly applied to living protoplasm. We 
shall choose for special discussion the effects of a limited number of ex¬ 
ternal conditions that are of interest because of their bearing upon phar¬ 
macology and therapeutics. 

All colloids, including those found in the living animal, are con¬ 
veniently classed, as we found above, into suspension colloids and emul¬ 
sion colloids. This classification is made, as was pointed out, on the 
basis of the relationship that exists between these colloids and the sol¬ 
vent in which they find themselves. The suspension colloids are not so 
intimately associated with their solvent as are the emulsion colloids. 
While we can readily separate the solvent from the colloid in the first 
case, this is done only with great difficulty in the second. It is possible, 
for example, to separate in some suspension colloids (the colloidal metals) 
the solvent from the colloid by suitable methods of filtration; in the emul¬ 
sion colloids no such simple procedures suffice. If we take a swollen 
piece of gelatin, for example, it is well nigh impossible to squeeze the 
water out of it by any gross mechanical means. 

Of the colloids that compose the mass of the animal body, the emul¬ 
sion colloids constitute the chief hulk. In muscle, for example, we have 
about 75 per cent water. Of the 25 per cent of solids, only 1 per cent is 
ash; the rest is, in the main, emulsion colloid material. 

Of the emulsion colloid material found in any cell or group of cells 
in the animal organism, the main hulk is protein, and, as this has been 
studied with special care by Hofmeister, Spiro, Pauli, Hardy, Wolfgang 
Ostwald, von Schroeder, Handovsky, Schorr, Gertrude Moore and myself, 
we will devote our chief discussion to it. In this way we shall get at 
once not only a simple explanation of many phenomena that are familiar 
to every worker in medicine, but valuable principles upon which to base 
a rational therapy. 


EXTERNAL INFLUENCES ON COLLOIDAL STATE 33 


The proteins and the effect of various external conditions upon them 
have been studied from many points of view. Those which are most 
important from a medical standpoint are the relationship of water ab¬ 
sorption to the state of the colloid, the viscosity of the colloid, and the 
precipitation or coagulation 2 of the colloid. As we shall see shortly, a 
very simple relationship exists between these apparently detached prop¬ 
erties of the colloid. To indicate the importance of a knowledge of the 
changes that occur in these simple properties of the colloids under various 
external conditions, we need but mention the fact that the first of these 
properties of protein colloids controls, in the main, the whole question of 
how much water the cells or fluids of the body will hold under physio¬ 
logical and pathological conditions (normal cell turgor, edema) ; the 
viscosity of protein solutions is associated with the work the heart must 
do in pumping the blood, the general problem of protoplasmic motion 
(migration of leukocytes, contraction of muscle), and the phenomena of 
cell division; their precipitation and coagulation, with such changes as 
the steaminess of the cornea in glaucoma, the graying of the parenchy¬ 
matous organs in “cloudy swelling,” the changes produced by acids, 
caustics, and the metallic salts in pharmacology, etc. 

It is convenient to begin our discussion with the matter of water 
absorption by such protein colloids as gelatin or fibrin. 

When gelatin or some powdered fibrin is thrown into water it swells 
up somewhat. If the experiment is done quantitatively, and the gelatin 
or fibrin is thrown instead into a dilute acid, it is found that the col¬ 
loid swells up very much more. Depending upon the concentration of 
the acid, these colloids swell more and more with every increase in the 
concentration. But this is true only within certain limits. After a time 
a point is reached where the gelatin or fibrin does not swell more with 
a further increase in the concentration of the acid, but less. While all 
acids make gelatin or fibrin swell, they are not equally powerful in this 
regard. When equinormal acids are compared, hydrochloric acid is found 
to act more powerfully than nitric, and this more powerfully than lactic 
or acetic, in the order named. Sulphuric acid stands below these organic 
acids. 

These simple facts are of the greatest biological importance. What 
we have said regarding the action of acids on protein colloids can be said 
without modification for the effect of acids in the most varied physio¬ 
logical and pharmacological reactions. The same laws govern the way 
in which these acids reduce the irritability of nerves and muscle, kill 


3 It is necessary to distinguish between these two terms, for they represent radically 
different changes in the state of a colloid. We use the term precipitation if the change 
is reversible. We speak of the precipitation of a protein with a salt of some kind, if, 
on removing the salt, the protein goes back into solution. If it fails to go back into 
solution, we say it is coagulated—in other words, the change is irreversible. 



34 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


bacteria and the cells of higher plants, affect the sense of taste, influence 
chemotaxis (Garrey), favor the absorption of water by animal and plant 
tissues, favor proteolysis under the influence of pepsin, etc. We are safe 
in believing, therefore, that the point of attack of the acids is the proteins 
in the tissues, and that they influence the various biological phenomena 
considered by changing the state of these colloids in the same way that 
they change the state of our gelatin or fibrin. 

The swelling of gelatin or fibrin in any acid solution is reduced 
through the presence of any salt, even a neutral salt. So, if we add sodium 
chlorid to a lactic acid solution, the gelatin or fibrin contained in this 
medium will not absorb as much water as when the salt is not present. 
The more salt we add, the more is the swelling of the colloid reduced, and 
if we add enough the swelling may be stopped entirely. 

While in general the observations mentioned in the foregoing para¬ 
graphs are correct, their interpretation is difficult because the older ex¬ 
periments were not performed with iso-electric gelatin or fibrin, nor was 
the hydrogen ion concentration of the solutions determined. As men¬ 
tioned above, Loeb has shown that proteins combine stoichiometrically 
with acids and alkalis. 

But the different salts are very unequally effective in this regard. If 
we compare a series of equimolecular salt solutions, say sodium salts, 
and at a concentration that we are likely to encounter under physio¬ 
logical or pharmacological conditions, it is found that these arrange them¬ 
selves in a characteristic order. The chlorid, bromid, and nitrate reduce 
the swelling of gelatin or fibrin in an acid solution less than do the 
sulphocyanate, iodid, or acetate, and these less than the sulphate, phos¬ 
phate, tartrate, or citrate. If, on the other hand, we compare a series 
of salts having a common acid, say a series of chlorids, the metallic 
elements in these salts assume a characteristic order. Ammonium, potas¬ 
sium, and sodium stand near each other; far more powerful than these 
are magnesium, calcium, barium, and strontium, and yet more powerful 
are copper and iron. 

When compared with the powerful effects of the electrolytes, the 
non-electrolytes have but little effect in reducing the swelling of gelatin 
or fibrin in an acid solution. The amount of water absorbed by a given 
mass of gelatin or fibrin in a given concentration of acid is practically 
uninfluenced through the addition of urea, or ethyl or methyl alcohol. 
This is also true of glycerin, dextrose, saccharose, etc., in the lower con¬ 
centrations, though in higher concentrations these inhibit the swelling 
of protein colloids in an acid medium. The same is true of the effect of 
non-electrolytes on the swelling of gelatin or fibrin in an alkaline medium. 
The reason why we lay stress upon the behavior in an acid medium is 
because we are chiefly interested in the carnivora, and the whole chem¬ 
istry of these animals tends to run the reaction of their tissues over toward 


EXTERNAL INFLUENCES ON COLLOIDAL STATE 35 

the acid side. Carbonic acid is the common product of normal carbohy¬ 
drate and fat metabolism, and, when the normal metabolism gives way 
to an abnormal one, the tendency of the tissues to become acid is enor¬ 
mously heightened, for in place of carbonic acid much stronger acids are 
produced. 

These facts may be at once transferred to our knowledge of the 
pharmacological behavior of many items in our pharmacopeia. We can 
see, first of all, why the electrolytes are in general far more active physio¬ 
logically than the non-electrolytes. But we can go further than this. 
That long series of physiological reactions, which we have found to be 
identical point for point with the reactions of these simple colloids toward 
various external conditions, may now safely be regarded as reactions on 
the part of the colloids of the cell toward these same external conditions. 

A substance like fibrin, under ordinary circumstances, merely swells 
up in water; it constitutes a semisolid mass. ' The same is true of gel¬ 
atin at lower temperatures. We can, without overstating the case, make 
the behavior of tiny fragments of fibrin identical with the behavior in 
certain directions of individual cells. Tiny fragments of fibrin have 
the consistency, the pliability, and the powers of water absorption and 
secretion that are possessed by the individual body cells, say, for exam¬ 
ple, the red blood-corpuscles. Fibrin behaves, therefore, like the solid 
constituents of our bodies. A mass of fibrin or a gelatin cake behaves 
not unlike a mass of animal cells. In certain directions a mass of gel¬ 
atin behaves like a muscle, an eye, a kidney, or a brain. But such semi¬ 
solid structures do not compose all of our bodies. Permeating these, we 
have streams of liquid colloid material called the blood and lymph, that 
are kept in constant motion by the heart, the pressure of muscles upon 
the vessels, the aspiration of the thorax, etc. We have been content to. 
speak of these circulating streams, thus far, in their relationship to the 
body cells, as identical with the pond water that washes about our primi¬ 
tive ameba. And this remains true, but there is one important difference 
between the pond water and our blood and lymph. This depends upon 
the fact that pond water is practically free from colloids; it is to all in¬ 
tents and purposes plain water, in which some crystalloidal electrolytes 
and non-electrolytes are dissolved. Blood and lymph, on the other hand, 
are high in colloids. The water in pond water is essentially free. In 
the blood and lymph there is no free water; all the water is held in 
combination with the colloids found in them, and the electrolytes and non¬ 
electrolytes of the blood and lymph are carried in this colloid-water 
matrix. 

The blood is essentially liquid in character. It corresponds in its 
behavior not with a solid cake of gelatin, but rather with a solution of 
gelatin; not with a mass of solid albumin like fibrin, but with a dissolved 
albumin like egg white, a globulin, or serum albumin. Let us ask, there- 


36 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


fore, how such a solution of a protein colloid behaves under various ex¬ 
ternal conditions. For an answer to this question we are especially 
indebted to Franz Hofmeister, Wolfgang Pauli, W. B. Hardy, P. von 
Schroeder, Hans Handovsky, and K. Schorr. When we deal with such 
liquid colloids we cannot use the characteristics that served us in a study 
of gelatin and fibrin. The absorption of water, for example, by a gelatin 
plate can be accurately followed by weighing the plate; in the case of 
fibrin we can measure the height to which weighed quantities of this sub¬ 
stance rise in glass tubes of a standard diameter. In the case of a colloidal 
solution we may use changes in its viscosity, changes in its precipitability 
or coagulability under the influence of heat or various electrolytes and non¬ 
electrolytes, or changes in its optical behavior. While we shall learn 
later that all these are measures of the same type of change in the colloid, 
these properties are individually of such great biological and therapeutic 
importance that their individual discussion is not without value. A 
change in the viscosity of the blood constitutes one of the great variables 
in the circulation, which determines how much work the heart must do to 
keep this fluid circulating; precipitability and coagulability of the liquid 
colloids of the body are associated with the production and absorption of 
corneal opacities, the changes incident to exposure of parts of the body 
to heat and cold, the phenomena of blood and lymph coagulation; the 
optical properties of a colloid solution are associated with the mainte¬ 
nance of the normal, and the establishment of abnormal indices of re¬ 
fraction in the clear media of the eye. 

Wolfgang Pauli has studied a very pure liquid albumin by working 
with blood serum from which the various admixed crystalloids have been 
removed through long dialysis of the blood against distilled water. Such 
a solution is perfectly clear and entirely stable. If the viscosity of such 
a preparation is measured, it is found to be considerably higher than that 
of pure water. If a trace of acid is added, the viscosity is enormously 
increased. But to this there is an upper limit. In the case of such acids 
as hydrochloric, hydrobromic, nitric, or sulphuric, a point is finally 
reached where a further increase in the concentration of the acid does 
not further increase, but decreases, the viscosity. For the weaker organic 
acids no such optimal point has yet been found. 

The addition of any salt to an acidified albumin markedly reduces 
the viscosity. The addition of a non-electrolyte is conspicuously less 
effective in this regard. With the same salt the degree of reduction of the 
viscosity increases with every increase in the concentration of the added 
salt. With a given concentration of any series of salts very different 
effects are obtained. So, for example, when sodium salts are compared, 
the chlorid, nitrate, and sulphocyanate are found to be less powerful in 
reducing the viscosity of an acidified albumin solution than the acetate 
or sulphate. 


EXTERNAL INFLUENCES ON COLLOIDAL STATE 37 

A practically identical series of findings has been established for the 
effects of alkali and of alkali plus various electrolytes and non-electrolytes 
on liquid protein. 

It is readily apparent from these remarks that the changes in the 
viscosity of a liquid protein and the absorption and secretion of water 
by gelatin or fibrin under identical conditions parallel each other. The 
fundamental change underlying both may, therefore, be looked upon as 
being the same. We shall call it a change in the hydration capacity of 
protein colloids. What makes our gelatin or fibrin swell increases the 
viscosity of serum albumin, and vice versa. What increases the hydration 
of a colloid increases the intimacy of its relation to its solvent, and so 
the stability of the colloidal solution. It will not surprise us, therefore, 
to have it pointed out that those conditions which increase the hydration 
capacity of the protein colloids are the conditions which increase this 
stability, while, conversely, those which decrease this must favor the pre¬ 
cipitation and coagulation of the protein. A few illustrations of the 
behavior of protein toward various precipitants and coagulants will make 
this clearer. 

The pure serum albumin already discussed is readily precipitated by 
heat or through the addition of alcohol. When a little acid is added to 
the blood serum the hydration capacity of the colloid is increased, and, 
corresponding therewith, its precipitability through heat or alcohol is lost. 
But if yet more acid is added the hydration optimum for the protein is 
exceeded, and now the heat and the alcohol again regain their power to 
precipitate the protein. In a similar way the protein that has lost its 
precipitability through heat, by having an acid added to it, has it restored 
when any salt is added, just as we previously found this to decrease its 
hydration capacity. 

In this way we see how a series of reactions in certain protein colloids, 
which at first sight seem to have nothing to do with each other, all come 
to be reducible to a comparatively simple series of changes. And so we 
also see how apparently widely separated and unrelated physiological, 
pathological, and pharmacological phenomena all come to be the expres¬ 
sions of the same simple underlying colloid truths. The mercury salt 
that kills bacteria makes the tears flow and maybe blinds an eye; that 
kills in the same way some of the intestinal flora, produces a diarrhea 
and perhaps a coagulation necrosis of the mucous membrane, is only an 
electrolyte that is peculiarly powerful in making the hydrated protein 
colloids which we find in the body give up their water and suffer the 
optical and solubility changes that go with this process. And the changes 
that characterize a glaucoma, a nephritis, or a generalized edema are in 
the main only the expression of an increased hydration capacity of the 
tissue colloids involved, and can be relieved by using those same elec¬ 
trolytes which we found especially effective in decreasing the hydration 


38 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


of these same body proteins upon which any one may work in his 
laboratory. 


EFFECT OF COLLOIDS ON CRYSTALLOIDS 

The previous paragraphs dealt in the main with the effect of various 
external conditions, notably various crystalloids, upon the state of the 
colloids that are of importance in the body. We wish now briefly to point 
out the fact that colloids also affect the state of the crystalloids that are 
brought in contact with them. So many problems in pathology and pre¬ 
ventive medicine are associated with changes in the solubility character¬ 
istics of various substances found in our tissues and their secretions, that 
a brief reference to this problem is not out of the way. Not only is a 
normal or abnormal formation of bone a problem of this character, but so 
is the formation of concretions in the brain, in the gall-bladder, in the kid¬ 
ney or bladder, or the deposition of urates, etc., in the joints. 

Wolfgang Pauli and M. Samec have made a careful study of the 
solubility of various substances in colloidal protein solutions as compared 
with the solubility of these same substances in water. In general it may 
be said that the solubility of easily soluble electrolytes is slightly decreased 
through the presence of colloid material, while the solubility of difficultly 
soluble substances is, on the other hand, often very decidedly increased 
by this means. The removal or a change in the state of the colloid con¬ 
stituents of a body tissue or a body fluid, be this wrought through bacteria, 
a dietary regime, or a pharmacological preparation, may, therefore, he 
followed by consequences which, on the one hand, determine the relief of 
a rickets, the prevention of an attack of gout, or the prevention of the 
formation of a new set of kidney stones; on the other, by the hastening 
of an arteriosclerotic process, or the deposition of more urates, bile salts, 
or earthy phosphates in the form of stones. 


SURVEY OF APPLICATION 

We have laid special stress thus far upon the application of an 
isolated number of physicochemical conceptions to the individual cell. 
We have now to discuss these conceptions from the standpoint of groups 
of cells, for instance, as in such a multicellular organism as man. We 
will find that the same laws are operative here, but some have acquired an 
exaggerated importance, while others are hidden behind the complicating 
circumstances that spring out of the- fact that the cells exist no longer 
individually, but in groups, and that special arrangements have been 
introduced to make life in such large groups possible. We no longer 


SURVEY OF APPLICATION 


39 


deal with the individual, but with the society made up of individuals, 
and, while the physiology of the whole is still only the compound 
physiology of the individuals, these individuals have so specialized in 
their work and have introduced such new schemes into their collective life, 
that this at first sight seems different from that of the individual who 
went to form the society. But it is not. A second fact that must have 
become apparent is that we have not been able to hold closely to our 
subject of therapy, but that we have found it necessary to move rapidly 
and easily between the realms of pure chemistry and physics and those 
of physiology, pathology, and pharmacology. The reasons for this are 
obvious. No real distinction exists between these realms. A therapy 
that involves discussion of so simple a matter as the role of sodium chlorid 
in the diet cannot be handled in any isolated way; we must know the 
role played by sodium chlorid and the theory of its action in normal 
physiology before we can intelligently discuss the effects of its elimination 
or its addition to the diet under physiological or pathological conditions. 

Let us now see what use may be made of the principles discussed 
in the preceding pages when we deal with so complex an organism 
as man. We will begin with the role of water in our everyday therapeutic 
procedures, for, as we shall find, behind the biochemical behavior of 
water there is many a problem that at first sight appears to have nothing 
to do with this. 

Role of Water. —We ordinarily take the metabolism of water in the 
body largely for granted. According to his desires, the normal individual 
consumes per day several liters of water or liquids containing water, 
and after a comparatively short latent period he again eliminates this 
water in the form of urine, sweat, or through the breath. Water has 
gone into the body and come out again, and the body is to all intents 
and purposes unchanged. And this is why we are so likely to ignore 
entirely this most important function. 

From these simple statements, let us remember first of all that we 
get a urinary output (or an output of water from the lungs or the skin, 
if the temperature is high) that is proportional to the amount of water 
consumed. The fact that the law of the conservation of matter and 
energy works for water as for any other substance introduced into the 
body is overlooked all too often in our daily practice. When we wish 
more urine (or sweat), we must give more water, and, other things 
being equal, we shall get this in proportion to the amount of water 
consumed. While a cry for more urine is heard daily in every hospital, 
the fact that we can obtain it only by giving more water to our patient 
is as constantly ignored. Only water will yield more urine. It is the 
one and only diuretic. The substances that we call diuretics are such 
only because they aid in supplying water, as we shall see shortly. 

The loss of balance between the intake of water and the elimination 


40 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


of water from the body represents a pathological state. When water is 
retained in the body we call it edema. The opposite state is represented 
by an abnormal loss of water from the body, and is not so much dis¬ 
cussed. Why has the normal body so constant a content of water, and 
what has happened when a patient has developed an edema or lost an 
abnormal amount of water ? What principles must guide us in the treat¬ 
ment of the two last-named conditions ? 

The absorption and secretion of water by all cells and tissues that 
have been examined thus far have been found, point for point, to be 
identical, both from a qualitative and a quantitative viewpoint, with the 
absorption and secretion of water by such protein colloids as fibrin, gel¬ 
atin, or serum albumin. Our ameba has a certain size under normal 
conditions in its pond water. This is identical with the amount of water 
absorbed by a flake of fibrin placed in ordinary water. If we add a 
little acid to the pond water, the ameba swells, or, if we add salt, it shrinks. 
This again is identical with the behavior of the fibrin flake in a dilute 
acid, or in a solution of salt. 

A complex organism like a human being behaves in to to like the 
ameba. Under normal circumstances it has a certain water content 
which we cannot increase or decrease by the giving of water alone, any 
more than we can increase the amount of water held by the ameba 
by increasing the size of the pond in which he swims. 

The human body is a system of colloids that is saturated with water, 
and mere water drinking, for example, will not increase the amount of 
water these colloids will take up. 

How can we produce an edema? We can produce this only by in¬ 
creasing the capacity of the tissue colloids for water, so that when water 
is offered to them they will swell. The conditions that will thus increase 
the water capacity of colloids are various. In the case of the protein 
colloids we found that acids are particularly potent, and so are the 
various proteolytic enzymes. Under the influence of an abnormal acid 
(or an accumulation of other substances that are capable of increasing the 
hydration capacity of the tissue colloids) we might, therefore, if a source 
of water is available, expect to have a water retention occur. The 
body colloids will swell; in other words, an edema will result. That 
such is the case has been proved by many experiments. Not only will 
injection of acid into an animal lead to the development of a generalized 
edema, hut the various conditions that are known to lead to a water 
retention in the body are all such as have associated with them an 
abnormal production or accumulation of acid in the tissues, as, for 
example, heart disease, respiratory disease, blood-vessel disease, passive 
congestion, intoxication with anesthetics, intoxication with certain metals, 
intoxication with the toxins of many infectious diseases, etc. On the other 
hand, we have learned methods by which we can decrease the capacity 


SURVEY OF APPLICATION 


41 


of the tissue colloids for water. So, notably, we found that the various 
salts are active in this regard. We have normally a certain salt con¬ 
centration in the body. If we increase it, the tissues give up water and 
the whole body loses weight, exactly as does our ameba when we drop 
him into a salt solution of a higher concentration than pond water. In 
the same way we lose water if hypertonic salt solutions are injected 
into our blood-vessels, if we take a cathartic salt, or if we try to subsist 
on sea water. 

An abnormally high or low water content may involve the whole body 
or it may involve predominantly only a single organ or set of organs. 
It may last a long time, as in elephantiasis; or only a short time, as in 
the loss of water following a cathartic. The abnormally high water con¬ 
tent of various organs has, on the whole, the greater interest. This is 
the prominent sign in many a specially named pathological condition. 
So, for example, in the edema that affects the eye (which we call glau¬ 
coma), in that which affects the kidney (which we call nephritis), in 
that which affects the parenchymatous organs (which we call cloudy 
swelling). The important point in all this, from a therapeutic basis, is 
that just as we can reduce the normal water content of cells and tissues 
by various salts, so can we reduce an abnormally high water content in 
these edematous states and by the same means. The saline cathartic 
that makes the normal body give up water will also make the edematous 
body or organ give up water, and here we have a rational explanation 
of the beneficent effects of the long-established therapeutic use of these 
cathartic salts in edema. But the explanation of how they act has been 
lacking. We have been in the habit of saying that a cathartic salt 
makes for a secretion of water into the bowel, and so for a loss of 
water from the edematous tissues. It is more correct to say that the 
salts diffuse into the tissues, which then liberate water. This “free” 
water comes out either through the bowel or through the kidneys. And 
now we see, too, why the saline cathartics have so long been identical 
with the saline diuretics. They act on the tissues with which they 
come directly in contact (bowel and kidney), and they also act on all 
the other tissues of the body, an action quite as important as that on the 
bowel and kidney alone, for only in this way is “free” water rendered 
available for elimination by these secretory organs (see page 43). 

The electrolytes all decrease the capacity of the tissue colloids for 
water. As sodium chlorid is one of these, we shall be unable to sub¬ 
scribe to the idea that a restriction of this salt in the diet is right when 
we are trying to reduce the edema in a patient. Sodium chlorid should, 
on the contrary, be urged upon the patient in his food, between meals, 
and, if necessary, it should be given him by rectum or intravenously. 

Whether we deal with a generalized edema or with a local one, the 
principles underlying its-relief are always the same. Therefore we shall 


42 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


not be surprised to find that, just as sodium citrate will make the 
intestinal mucous membrane give up water, it will also, when injected 
subcon junctivally, make a glaucomatous eye give up water, so relieving 
the glaucoma. Or, if a kidney has ceased to functionate because of a 
pregnancy intoxication or the action of an anesthetic or the toxin of an 
acute infectious disease, this may usually be relieved by injecting sodium 
chlorid (and sodium carbonate to neutralize acid) intravenously in hy¬ 
pertonic solution. This makes the kidney colloids shrink, and the de¬ 
crease of swelling allows the kidney to get a normal blood supply once 
more. By acting upon the edematous brain, the edematous optic nerves, 
and the body tissues generally, it reduces the headache, vomiting, blind¬ 
ness, and the edema of the body tissues generally. At the same time 
the water freed in this way becomes available for urine, and the urinary 
output rises. 

While treatment of diseases associated with edema may be attended 
frequently with success, when conducted according to the principles out¬ 
lined in the preceding paragraphs, certain reservations should be men¬ 
tioned. The mechanism which maintains the acid base equilibrium in 
the body so constantly at a reaction between 7.8 and 7.0 can admit of no 
acid changes within the cellular systems in any way comparable to those 
employed in the gelatin and fibrin swelling experiments. That changes 
in pH within the cell, outside the range maintained in the blood and 
body fluids, may occur is possible; and may in turn account for certain 
dropsical conditions encountered in medical practice. Furthermore, we 
should not lose sight of the fact that no matter how much sodium bicar¬ 
bonate we may take by mouth, or intravenously, the pH of the blood 
and body tissue remains nearly constant; also in practice we rarely 
find cases with edema that have the bicarbonate content of the blood 
markedly reduced. If we grant that within cells a more acid reaction 
may develop than is found in the body fluids in general, the neutralization 
of this acid may be supposed to take place more readily when the 
concentration of bicarbonate is raised, thereby leading to greater pene¬ 
tration power on the part of the alkali. We are not yet ready to admit 
of the general application of principles outlined, for it is a matter of 
clinical experience that certain cases of renal disease with edema are 
made worse when large amounts of salt, bicarbonate and water are given, 
instead of restriction of these substances. 

In this connection it is well to emphasize two more points. The first 
of these is the reciprocal relationship that exists between the various 
secreting organs of the body. Since the sine qua non of every secretion 
is the obtaining of free water, it is clear that, if we use this up for one 
secretion, we cannot have it for another—a point that is frequently lost 
sight of. If we wish to have urine from a kidney we cannot expect it 
if we are robbing the body of all its free water by sweating our patient 


SURVEY OF APPLICATION - 


43 


(unless we cover this by giving water) ; or, if we are robbing the body 
of water through a secretion into the bowel, we cannot at the same time 
have the water for urinary output or sweat. 

If these physicochemical conceptions are correct, then we have also 
an insight into the “diuretic” action of various pharmacological products. 
I he caffein derivatives and digitalis will serve as good examples. 
We have already emphasized the fact that only “free” water goes to 
the formation of any secretion. These “diuretics” can act, therefore, 
only because they furnish free water. This they do by increasing the 
force or the frequency of the heart beat and the depth and rapidity of 
respiration. In this way there is kept in contact with the body tissues 
a blood higher in oxygen and lower in carbonic acid than is the case when 
these drugs have not been taken. By this means the normal (or abnor¬ 
mal) acid content of the tissues is reduced, in consequence of which the 
hydration capacity of the tissue colloids is decreased. “Free” water is 
then given off to the blood, which may then escape as urine (or as some 
other secretion). 

Conversely, we may expect a drop in all the secretions and a reten¬ 
tion of water if we give any drug that has an opposite effect. The anes¬ 
thetics, alcohol in large amounts, atropin, morphin, etc., are examples of 
this class. These all permit a greater than normal accumulation of car¬ 
bonic (and other) acid in the tissues, and correspondingly they will de¬ 
crease the output of urine, create thirst, lead to constipation, check sweat¬ 
ing, etc. At the same time we learn from these simple facts that a 
reciprocal relation exists between the matter of water absorption and 
water secretion—the one is a mirror of the other, and that which favors 
the one at the same time hinders the other. 

What we have said holds for the ill as for the well body. In con¬ 
cluding these paragraphs it is only necessary to point out that, while in 
the ameba we deal with a mass of colloid material so small that secre¬ 
tion or absorption affects the whole, this does not follow in the case 
of so large a colloidal mass as the human being. Here one organ 
or set of organs may be busily absorbing water, while another is equally 
busy giving it up. A few words regarding this are of therapeutic 
interest. 

The problem involved is clearly presented to us under physiological 
conditions in that almost any amount of water we choose to consume is 
absorbed from our intestinal tract, while an equal amount (skin and 
lungs ignored) is given off by the kidneys. What is the mechanism that 
accomplishes this? 

Let us first ask what happens to the swallowed water, and how it 
goes to form urine. What have these problems to do with our ameba 
swimming about in its pond? 

We have already paralleled the general processes of water absorption 


44 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


and water secretion in the ameba with the behavior of a fibrin flake un¬ 
der similar conditions. The ameba is a spherical mass of colloidal ma¬ 
terial that is saturated with water, and, through changes in its physico¬ 
chemical surroundings, or through direct changes in its own chemical 
composition, it at times takes up water (absorption), at times gives up 
water (secretion). But in a multicellular organism the phenomena of 
water absorption and secretion that confront us do not at first sight seem 
to be interpretable on any such simple basis as that outlined for the 
ameba. In man, for example, we find whole organs set apart, and seem¬ 
ingly endowed only with powers of absorption, while others are apparently 
set apart to functionate only as secretory organs. It becomes hard, 
for example, to see just what relationship exists between a mucosal cell 
of the small intestine, concerned almost exclusively with an absorption 
of water from the lumen of the gut, or a kidney cell, concerned equally 
exclusively with a secretion of urine, and the ameba which now absorbs 
and now secretes water either in response to its own physiological de¬ 
mands or under the conditions with which experimentally we are pleased 
to surround it. And yet on closer analysis the difference between the 
two is not so striking. 

First of all, we appreciate the fact that the mucosal cell is an ab¬ 
sorbing cell only so long as we look at it from the side of the lumen of 
the gut. If we regard it from the blood-vessel side, it is a secreting 
cell, for what it absorbs from the gut it gives up to the blood. Similarly, 
the kidney cell is a secreting cell only because we usually look at it 
from the point of view of being a producer of urine; as a matter of fact, 
everything that goes to make up the normal urine was absorbed from 
the blood. But, even if we look at the matter from the narrower point 
of view, the intestinal cells under certain circumstances become secreting 
cells, in that they secrete substances into the lumen of the intestines, 
and, according to judgment of some authors, certain kidney cells may 
reabsorb materials that have been secreted by others. In essence, there¬ 
fore, secretion and absorption in the higher animals are not different 
from absorption and secretion as observed in an ameba. That which 
remains, therefore, to characterize absorption and secretion in the higher 
animals is merely this: that, under normal circumstances and from 
the point of view of the organism as a whole, absorption and secretion 
occur predominantly in one direction. What require special analysis 
are the conditions existing in the multicellular organism which make 
it possible for certain cells and tissues thus to act predominantly 
as absorbing systems, while others act predominantly as secreting sys¬ 
tems. 

Let us see if we cannot define in general terms what must be the 
conditions lying at the bottom of this predominant functioning of certain 
cells and tissues in one direction, and do so on the basis of our belief 


SURVEY OF APPLICATION' 


45 


that the colloidal constitution of the living cell is primarily responsible 
for the phenomena of water absorption and secretion by the cell. 

The ameba, or an isolated cell or tissue derived from a higher animal, 
kept in a solution of any kind, is surrounded by this solution on all 
sides. Could we imagine the chemical processes within these cells held 
in abeyance, then we could see how these cells would after a time get 
into a state of equilibrium with their surroundings. When this is brought 
about the cells neither absorb nor secrete water. Only as this equilibrium 
is disturbed, either through changes in the surroundings of these cells or 
through the specific chemical changes occurring in the cells, can we 
expect a renewed absorption or secretion. 

Under quite different conditions do we find the individual cells of 
the multicellular organism existing in the intact living body. While 
in a certain sense the internal activities of the ameba may be compared 
with those of the individual cells making up, say, the intestinal mucosa, 
and there exists a certain analogy between the fact that both are sur¬ 
rounded by a liquid medium, with this the analogy stops. For, while 
the ameba is surrounded on all sides by the same liquid medium, the 
cells of any of the absorptive or secretory organs found, for instance, in 
a mammal, are, with different parts of their cell protoplasm, in contact 
with entirely different media. The cells constituting the intestinal mu¬ 
cous membrane are bathed on the one side by intestinal contents, while 
on the other they are bathed by blood or lymph, or both together. Such 
cells, like any other absorptive or secretory cells similarly situated, are, 
therefore, in the predicament of trying to get into equilibrium with as 
many different media as surround them. It is in trying to do this that 
all the phenomena which we call absorption and secretion in the higher 
animals are produced. It is during its attempt to get into equilibrium 
with the intestinal contents on the one side and the blood on the other 
that the mucosal cell (better, the colloidal membrane separating the in¬ 
testinal contents from the blood) absorbs the intestinal contents and trans¬ 
fers them to the blood. 

The body of a multicellular organism, such as a mammal, is like the 
individual ameba built up of colloidal material, which in the resting 
state is saturated with water. To be counted in with the colloidal struc¬ 
tures that make up this water-saturated colloidal system of the mammal, 
and composing an integral part thereof, are the blood and the lymph. 
The entire system will not take up more water, nor give up any, except 
as chemical changes are first produced in it which either increase or de¬ 
crease the capacity of the tissue colloids for water. 

The relationship between the absorption of water from the intestinal 
tract and its secretion subsequently by the kidney is easily understood 
when the following is borne in mind. The cells of the small or large 
intestine will absorb water only if they are not already saturated with 


46 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


water. In consequence of the carbonic acid production in these cells, 
they are rendered capable of taking up water from the intestinal lumen. 
But, as the blood circulates through the intestinal mucous membrane, 
the carbonic acid diffuses over into it. Two changes follow this: first, 
the capacity of the colloids in the mucous membrane to hold water is 
diminished; and, secondly, the capacity of the blood (which we have said 
represented a water-saturated colloidal solution) to take up water is 
at the same time increased. A minimal calculation shows that a liter 
of blood in passing through the intestinal tract, where it changes from 
arterial to venous blood, is made capable in this way of taking up at 
least 17.5 cubic centimeters of water. As long as the circulation is 
maintained, and as long as the cells produce carbonic acid, the intes¬ 
tinal tract must, therefore, absorb water, if this is made available by 
being in the lumen of the gut. Evidently the higher the carbonic acid 
(or other acid) content of the blood, the better absorbing medium for 
water must it become. And so we are not surprised to note that water 
is best absorbed from the large bowel where the blood has a most highly 
venous character, and less.well from the small intestine, where this is not 
so markedly true. Water absorption from the stomach is scarcely pos¬ 
sible, for this is so richly supplied with arterial blood that its acid content 
scarcely varies. 

Just the reverse conditions are necessary if we are to obtain a secre¬ 
tion of water. A secretion can be gotten only from arterial blood, that 
is to say, blood low in carbonic (or other) acid. The venous blood, 
which has grown rich in carbonic acid and water in its passage through 
the intestine, loses the carbonic acid (as C0 2 ) when it passes into the 
lungs. When this happens the colloids of the blood can no longer hold 
all the water they had absorbed, so it becomes “free.” This arterial 
blood with its “free” water passes to the kidney, and here the free 
water is eliminated as urine. 

We are not surprised on this basis to find that during absolute starva¬ 
tion the secretion of urine ceases (practically) entirely. If the colloids 
of the body as a whole are saturated with water, none is left over to be 
secreted. Only as the tissues undergo a gradual consumption during 
starvation, or their colloids suffer changes which decrease their capacity 
for holding water, is any liberated to become available for secretion. 

On the other hand, as we have already pointed out, if an animal that 
has its body colloids saturated with water consumes a quantity of water, 
after a time an amount of urine (or sweat or breath moisture) is se¬ 
creted which is equivalent to the amount that has been drunk. It does 
not matter how this water was introduced into the organism. It may 
have been swallowed or introduced through a stomach tube into the gas¬ 
trointestinal tract, or it may have been injected into the peritoneal cav¬ 
ity, under the skin, or directly into the blood. But let it be noted that 


SURVEY OF APPLICATION 


47 


the diuresis occurs only in proportion to the amount of “free” water 
present; in other words, as water not combined with a colloid. 

Ihe correctness of these ideas is at once proved when we make the 
experiment of injecting intravenously in place of a physiological salt 
solution an equal volume of a solution in which the water is not “free,” 
but combined with a colloid (that is, in the form in which it exists in 
the body cells and fluids normally). Under such circumstances no in¬ 
creased water secretion in the form of urine (or sweat) results. When 
blood or blood serum or a gelatin solution is injected intravenously, no 
increased urinary output follows. 

These facts are of considerable therapeutic worth. We have empha¬ 
sized the fact that, if we would get any urine (or sweat) from a patient, 
we must first have all his tissue colloids saturated with water. After this 
has been accomplished, we shall obtain from him a urinary (or sweat) 
output only as we have administered water over and above the amount 
necessary for the saturation of all his colloids. Then we shall have a 
urinary output that is in proportion to the amount thus introduced. The 
blood is not that fathomless well for urine that many clinicians imagine 
it to be. 

Let us ask now what happens, so far as urinary secretion is concerned, 
if we introduce with a given quantity of “free” water varying amounts 
of any salt. In discussing the absorption of water by protein colloids 
we found that all salts decrease the capacity of these colloids for holding 
water. We are not surprised, therefore, to note that if we inject progres¬ 
sively stronger sodium chlorid solutions intravenously we get (with a 
constant amount of water injection) a corresponding increase of urine. 
It is ordinarily said that such salt solutions “stimulate” the kidney. 
Aside from the fact that the word stimulation means nothing, this is 
too narrow an interpretation of the case. As we give progressively 
stronger salt solutions, we increase more and more the concentration of salt 
in the body tissues, which then give up water. This water is “free” and 
adds itself to the free water that we have introduced; therefore, we 
have a greater amount available for secretion as urine, sweat, etc. 

While sodium chlorid makes a protein colloid give up water, other 
salts, like sodium phosphate, sodium sulphate, sodium citrate, magnesium 
sulphate, magnesium citrate, etc., act far more powerfully in this direc¬ 
tion. It is because of this more powerful action that they are called 
the saline diuretics. Their behavior is to be explained in the same way 
as the behavior of sodium chlorid—they make the tissues of the body 
yield up water. 

The list of these saline diuretics is identical with the list of the 
saline cathartics. The reason for this is obvious. The saline cathartics 
do to the gastrointestinal tract what they do to any protein colloid, as 
F. Hofmeister first showed. In spite of the many complex explanations 


48 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


of the action of the* cathartic salts that have been advanced since 
Hofmeister’s work, we are destined to accept his explanation. 

We have now to look at our problem from another point of view. 
While sometimes we desire the body colloids to give up water, nature 
at times furnishes pathological conditions in which we desire just a 
reverse result. 

We can illustrate what is meant by referring to the problems pre¬ 
sented by such conditions as hemorrhage and shock. The two conditions 
are mentioned in the same sentence not alone because, from a clinical 
standpoint, they have much in common, but because this is also true 
from a therapeutic standpoint. In both we have a diminution in the 
volume of the circulating blood, and a good part of the therapy of 
these conditions consists in combating this sign by attempting to increase 
the volume of the circulating blood. The various therapeutic schemes 
that have been devised to accomplish this end are familiar to every one. 
What are their relative merits ? 

It is at once apparent that the injection of salt solutions into such 
individuals can yield only temporary results. We inject free water in 
this way, and free water does not remain in the blood-vessels, but es¬ 
capes in a short time through the various secretory organs of the body, 
or is sucked into the tissues which, in hemorrhage or shock, are likely 
to have an increased capacity for water. Only water in combination 
with a colloid will and can remain in the blood-vessels, and hence the 
better results to be obtained by introducing, instead of salt solutions, 
blood, blood serum, or, if necessary, gelatin solutions. 

The same problem confronts us in the treatment of such a condition 
as constipation when due, as is so often the case, to a too perfect absorp¬ 
tion of water from the intestinal contents. When we do not wish to 
prevent so perfect an absorption of water from the intestinal tract by 
giving cathartics which tend to make for a secretion of water into the 
bowel, then we can regulate the process by feeding material from which 
the intestinal mucous membrane cannot absorb the water. It cannot do 
this if we keep the water in the intestinal contents bound to a colloid. 
That is what happens when we prescribe a diet rich in cellulose, or add 
to the ordinary diet such substances as agar-agar, or the various Japanese 
sea-weeds from which this is made. Cellulose and agar-agar are colloidal 
substances that have a great affinity for water, so they hold it in the 
gastro-intestinal tract in spite of the efforts of the colloids of the intestinal 
mucous membrane to get it out. Because these colloids cannot get this 
water out, the intestinal contents remain soft, and so constipation is 
prevented. 

Absorption and Secretion of Dissolved Substances. —We have pur¬ 
posely laid so much stress upon the question of water absorption and 
water secretion from the body because the absorption and secretion of 


SURVEY OF APPLICATION 


49 


dissolved substances are intimately associated with and largely dependent 
upon this. Not only does this hold for the normal absorption and secre¬ 
tion of such substances as serve as foods or represent metabolic waste 
products, but also it holds for the absorption and secretion of substances 
which, either from a quantitative or a qualitative standpoint, are known 
to us as parts of our pharmacological or therapeutic armamentarium. 
The general problems of intoxication and detoxication are found here. 

Let us first look at the problem as a whole. 

We have in the earlier parts of this chapter always emphasized the 
behavior of the individual cell. The reason for this lies in the fact that 
the multicellular organism and its behavior represent merely the com¬ 
pounding of the behavior of many such cells and different kinds of cells. 
So we shall not be surprised to find that everything we have said re¬ 
garding the unicellular organism holds for the multicellular one, except 
that in this certain additional factors are introduced which somewhat 
complicate the picture and demand separate analysis. 

But just as we were able in a rough way to look upon man, for ex¬ 
ample, as a huge mass of colloidal material which collectively resembled 
the small mass represented by an ameba in its behavior toward water, 
so similarly can we compare the large mass with the small in its be¬ 
havior toward dissolved substances. The ameba obtains all the various 
substances that it takes up from those which are dissolved in the water 
surrounding it; and it rids itself of such dissolved substances as it may 
have in excess in its protoplasm to this same water surrounding it. 

A human being does in toto the same thing, only the mass of water 
available for such purposes seems comparatively small, and the processes 
of absorption and secretion of dissolved substances seem to be more 
intimately associated with certain organs. Thus we usually absorb a 
food or a toxic agent from an aqueous solution of this contained in the 
gastro-intestinal tract: we rid ourselves of these same substances by 
giving off an aqueous solution of them that we call urine. But the 
processes involved in these apparently complex acts are in essence no 
different from those which we encountered in our ameba. 

All the absorbing and secreting systems that we encounter in the 
human body may be roughly divided into three phases. In the case of 
such an absorbing system as that presented by the intestine, these are 
represented by (a) the material to be absorbed, (&) the absorbing tissue, 
and (c) the blood or lymph. In the case of a secreting system, such as 
is represented by the kidney, we similarly recognize three phases: (a) 
the blood or lymph; (&) the secreting tissues; (c) the urine. 

Let us take up first the matter of absorption and see what the general 
mechanism of this is in the case of the human being. 

When we take a meal or swallow a drug it is practically equivalent 
to saying that we take an aqueous solution of something. This aqueous 


50 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


solution may contain colloids (such as our ordinary foods, the starches, 
proteins, and fats), or crystalloids (such as salt, cane sugar, strychnin 
hydrochlorid, or Fowler’s solution). This is the first phase of our 
absorbing system. 

The second is a colloid membrane that is made up of all the struc¬ 
tures lying between the solution of substances to be absorbed and the blood 
or lymph. This colloid membrane is, therefore, a fairly firm structure, 
like a water-soaked leaf of gelatin. Only it may not be so entirely 
homogeneous. For instance, we recognize the differences that may result 
from having different kinds of cells in this absorbing membrane, and- 
then between the different cells there may lie intercellular substances 
that need not be identical with the material that builds up any or all 
the various cells found here. But for the sake of simplifying our argu¬ 
ment let us imagine it to be entirely homogeneous. 

The third phase in our absorptive system is represented by the blood. 
This is also made up of colloidal material, but it is not solid, it is 
liquid. It corresponds, therefore, to a solution of gelatin. 

What must happen in such a system ? 

We have already discussed what must happen so far as the water 
contained in the first of these systems—that is, the water in the lumen 
of the gastro-intestinal tract—is concerned. The next fact to be empha¬ 
sized is that the absorption of this and the absorption of substances dis¬ 
solved in it are two distinct processes. A solution is never absorbed 
as such. 

Let us here interject that the mixture which we originally introduced 
into the gastro-intestinal tract undergoes a simplification to this extent: 
all the various colloids that may have originally been in it are converted 
into crystalloids before they are absorbed. From an academic standpoint 
this is not strictly true, but for practical purposes it is. The colloidal 
proteins are converted into amino-acids; the colloidal carbohydrates into 
dextrose; the colloidal fats into fatty acid and glycerol; colloidal drugs 
are converted into crystalloidal form, etc. 

Whenever a solution is seen to be absorbed we are observing the com¬ 
posite of the absorption of the solvent plus the absorption of each in¬ 
dividual substance dissolved in that solvent. For example, when any 
solution is introduced into the intestine, each' one of the dissolved sub¬ 
stances diffuses into the wall of the intestine until an equilibrium is es¬ 
tablished in the distribution of each of these substances between the 
liquid phase represented by the solution and the more solid phase 
represented by the (colloidal) intestinal wall. Similarly, every sub¬ 
stance present in the intestinal wall tends to diffuse out into the solution 
to the establishment of an equilibrium. In biological material it has been 
very generally assumed that the distribution of dissolved substances be¬ 
tween two such phases attains an equilibrium when the concentration of 


SURVEY OF APPLICATION 


51 


any dissolved substance is the same in both. Such an a priori conclusion 
is entirely unjustified. We deal in this problem with the distribution 
of a dissolved substance between water and a colloid, and, as we know 
from the facts now available on this subject, equilibrium may be reached 
when the dissolved substance is contained in less, the same, or a higher 
concentration in the colloid than in the solution surrounding it. 

Now, while the absorptive membrane is trying to get into equilibrium 
with the solution to be absorbed on the one side, it is also trying to get 
into equilibrium with the blood on the other. The problem of the 
“selective” absorption of the dissolved substance is the problem of the 
agencies concerned in establishing an equilibrium between all the various 
dissolved substances in these three phases. As we pointed out above, the 
factors of greatest importance in such a problem are the character of 
the various colloids concerned and their physicochemical state, as deter¬ 
mined through the presence of acids, alkalis, salts, and various non-elec¬ 
trolytes; the nature of the dissolved substances to be absorbed and their 
rate of diffusion; the presence or absence of lipoids in the colloidal ab¬ 
sorbing membrane and in the blood, etc. In other words, the laws of 
adsorption, of partition, and of chemical combination are all at work. 
Therefore, to the process of simple diffusion in this matter of absorp¬ 
tion (or secretion) become added a number of secondary phenomena 
that obscure its purity. But this does not make questionable the fun¬ 
damental importance of diffusion itself in the process of both absorp¬ 
tion and secretion. 

To illustrate, let us try to follow the relatively simple process of the 
absorption of a strong (so-called hypertonic) sodium chlorid solution 
introduced into the intestinal tract (or into the peritoneal cavity, or un¬ 
der the skin). Both the water and the salt immediately begin to diffuse 
into the absorbing membrane. As diffusion progresses, the concentration 
of the sodium chlorid in the absorbing membrane rises. This rise in 
concentration so affects the colloids of the absorbing membrane that they 
stop taking up water, or, if it becomes sufficiently high, an actual se¬ 
cretion of water into the gut or peritoneum or subcutaneous tissues re¬ 
sults. While this is occurring, an equilibrium is tending to be estab¬ 
lished between the sodium chlorid in the solution undergoing absorption 
and the salt in the absorbing membrane, but is never attained under 
normal circumstances, because the salt in the absorbing membrane is 
at the same time trying to get into equilibrium with the sodium chlorid 
in the blood. Now, since the blood is circulating, it is evident that the 
equilibrium is constantly being broken down toward the side of the blood. 
In consequence of this, more and more salt must move over into the blood 
(be absorbed). But, as this goes on, the colloids of the absorbing mem¬ 
brane again return to a. more “normal J state, and so the absorption of 
water, which could not occur before, can again take place. 


52 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


With a dilute (a hypotonic) solution of sodium chlorid, the water 
does not meet with so great a resistance to absorption, and it is possible 
for such a solution to become more and more concentrated as the water 
is (the more rapidly of the two) absorbed from it. Even salt solutions 
isotonic with the blood must be absorbed. We were never able to ex¬ 
plain this on our old osmotic conceptions of water absorption, because 
no osmotic differences exist in such a case to make the water move, but 
on the colloidal basis there is no difficulty in interpreting what happens. 
Let the colloids of the absorbing membrane take a little water from the 
isotonic solution and salt must quickly follow, for now its concentration 
is no longer in equilibrium with the sodium chlorid in the absorbing 
colloidal membrane. As the water passes over into the blood more water 
goes into the absorbing membrane, and then more salt, until all is ab¬ 
sorbed. Or we can start the absorption by having a little salt go in first, 
and then the water, etc., for, if the truth be told, we do not yet know 
just what characterizes the “isotonic” solution, nor shall we until the 
colloidal constitution of living matter has been adequately taken into 
account. 

As a final word let it be added that, on the basis of these colloidal 
conceptions of absorption, we experience no difficulty in understanding 
why any solution remaining for longer periods in the intestine or in the 
'peritoneal cavity may, while it is being “absorbed/’ have appear in it 
various substances found in the blood or tissues which it did not orig¬ 
inally contain. As dissolved substances diffuse out of a solution under¬ 
going absorption into the absorbing membrane until an equilibrium is 
established, just so, of course, must the substances contained in the ab¬ 
sorbing membrane tend to diffuse into the solution. 

The fact will, therefore, not surprise us that, when a mixture of 
different dissolved substances is offered the intestinal mucous membrane 
for absorption, these substances are not all absorbed at the same rate or 
in the same relative proportions. Neither are we surprised that the 
absorption is “selective.” We should be more surprised if it were not. 
The selective character of absorption depends upon the fact that the 
absorption of water and the absorption of dissolved substances are sep¬ 
arate processes. Of the dissolved substances each moves at its own rate 
and is influenced in its movement by factors that may not affect the others 
in the same way nor to the same degree. 

The mechanism of the secretion of dissolved substances is the mir¬ 
rored reflection of what has been said, and may be best outlined by dis¬ 
cussing the secretion of dissolved substances from such an organ as the 
kidney. 

What has been most difficult to explain in secretion has been its se¬ 
lective character; in other words, the ability of the kidney to separate 
from the blood a liquid which has a totally different quantitative and 


53 


SUEVEY OF APPLICATION 

qualitative composition. Qualitative differences are for the most part 
explainable through chemical changes that occur in the secretory cells 
themselves whereby substances are produced (such as mucin, for exam¬ 
ple) which do not appear in the blood at all. In other respects a secre¬ 
tion differs only in quantitative composition from the blood. This may 
go to the point of having entirely absent from a secretion certain con¬ 
stituents of the blood, as, for example, albumin from the normal urine, 
lor the most part, however, the secretion contains some substances in 
higher, others in lower, concentration than the hlood. To limit ourselves 
again to the urine, we need by way of illustration only recall that, under 
ordinary circumstances, the urine contains less chlorid than the blood, 
and more sulphates and urea. How are such differences to be explained ? 

To begin with, it is well to call to mind that a secretion of dissolved 
substances is possible only so long as water is furnished the living organ¬ 
ism. A secretion of water is necessary before we can hope to have any 
secretion of dissolved substances. This is a physiological truth that is 
utilized daily by the intelligent physician when he orders the drinking 
of large amounts of water to aid the organism in ridding itself of any 
poison, as the toxin of an infectious disease, for example. How the 
secretion of water by the kidney may be made a continuous affair we 
have learned from our previous discussion. How it must make for a 
continuous secretion of dissolved substance is apparent from what follows. 

Let us recall here our division of the urinary secretory system into 
its three parts: the blood, the secreting membrane, and the urine; and 
our brief characterization of the first as a liquid colloid in which various 
crystalloids are dissolved, of the second as a solid colloid also containing 
various crystalloids, and of the third as a watery solution of various 
crystalloids (practically) free from colloids. Thus far our discussion 
has shown that under the conditions normally existing in the body no 
water can be introduced into the blood without getting the secretion of 
an equal amount as urine. And what is secreted as urine is water, 
and only secondarily do substances come to be dissolved in it, so that it- 
assumes a chemical composition which permits it to be characterized as 
urine. Let us see now what must happen if some soluble (or pseudo¬ 
soluble) substance is introduced into the blood. To simplify the problem 
and not make our discussion unnecessarily long, let us think of the blood 
as one homogeneous system, and the urinary membrane as another. Un¬ 
der such circumstances one of the three possibilities presents itself from a 
physicochemical standpoint. The dissolved substance may distribute 
itself uniformly throughout the blood and the urinary membrane, or if 
may be present in either a greater or a less concentration in the urinary 
membrane than in the blood. Just what will happen is dependent upon 
the nature of the dissolved substance and the physical and chemical com¬ 
position of the blood and the urinary membrane at the time. Of greatest 


54 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


importance are such facts as the presence and absence of lipoids, the 
character of the colloids concerned, and the state of these colloids as 
determined by the presence of acids, alkalis, salts, or various non-elec¬ 
trolytes. In other words, the laws of partition and the laws of adsorp¬ 
tion again come into play. These differences in the distribution of a 
dissolved substance between the blood and the urinary membrane are 
rendered strikingly apparent when dyes are used as the dissolved sub¬ 
stances. 

But this distribution of a dissolved substance between the blood and 
the urinary membrane represents in the end only a static affair, and the 
secretion of dissolved substances in urine is a dynamic one. It requires 
no special comment to see now why only through the continuous secre¬ 
tion of water from the kidney can a continuous separation of dissolved 
substance from the urinary membrane (secretion) be rendered possible. 
The presence of water in Bowman’s capsule and in the uriniferous 
tubules introduces the third phase into our secretory system and con¬ 
tinuously breaks down the equilibrium that is trying to become estab¬ 
lished between the dissolved substance in the blood and the dissolved 
substance in the urinary membrane. 

The attempt to establish an equilibrium between the dissolved sub¬ 
stances in the urinary membrane and the dissolved substances in the urine 
(originally only water), as it passes down the uriniferous tubules, makes 
for a diffusion of dissolved substances out of the urinary membrane. 
Consequently as long as water is being secreted by the kidney this must 
tend to destroy the equilibrium which is trying to become established 
between the dissolved substances in the blood and the dissolved substances 
in the urinary njembrane. If we recall the physicochemical fact that, 
when any dissolved substance is offered simultaneously a liquid colloid, a 
solid colloid, and water (as is the case in the kidney), an unequal dis¬ 
tribution of the dissolved substance among the three phases is the rule, 
then we shall have no difficulty in understanding why a difference in 
quantitative composition between the blood, kidney tissue, and urine, 
so far as dissolved substances are concerned, is also the rule. There¬ 
fore, a “selective” secretion is to be expected rather than to be wondered 
at. 

Further than this we cannot pursue this subject at present. But in 
passing H should like to point out that the fruits of colloid chemistry 
help us to understand even the most radical differences that exist between 
secretions and their source. None is perhaps more striking than the 
strongly acid reaction of the urine or the gastric juice against the prac¬ 
tically neutral reaction of its source, the blood. But even these can be 
accounted for through the selective absorption by the colloids of the uri¬ 
nary membrane of the sodium dihydrogen phosphate, and by the colloids 
of the gastric mucosa of the hydrochloric acid of the blood. Such a con- 


SURVEY OF APPLICATION 


55 


centration of an acid by colloids from very dilute solutions of acid salts 
or acids has been proved directly. 

What we have said concerning the absorption of dissolved substances 
in the intestinal tract, and the secretion of dissolved substances by the 
kidney, may be applied with small variation to any other absorptive or 
secretory system that we find existing in the body. It may be applied 
also to any of the processes of absorption and secretion as these involve 
any cell, group of cells, or organ outside of those included in any special 
discussion of absorption and secretion. When we deal with such an 
organ as the brain, the spleen, or the adrenal, the system involved is 
really somewhat simpler than in the case of the intestine or the kidney. 
The individual cells of these organs are more like the ameba in its pond 
water—they are more nearly surrounded on all sides by the same fluid 
medium, and from this medium (the blood or blood plasma which we 
call lymph) they absorb the substances necessary for their existence or 
harmful to it, and, similarly, they give off to this medium their normal 
metabolic products or the substances which as toxic bodies may have got¬ 
ten into them. The whole problem, therefore, becomes in the main a 
distribution of dissolved substances between (roughly) two media, on the 
one hand the cells and their intercellular substances, on the other the 
blood (or lymph). 

The various normal and abnormal dissolved substances come to all 
the cells in the body through the same blood stream. The cells endeavor 
to get into equilibrium with each one of these substances. But, as the 
individual cells of the body differ from each other in chemical composi¬ 
tion, or as the same cell is in a different physicochemical state at differ¬ 
ent times and under different conditions, so will the different cells, or 
the same cell at different times, behave entirely differently toward the 
same dissolved substance or substances as these are brought to them in 
the blood. It is for this reason that not only the rate at which any 
dissolved substance is taken up will be different for different cells 
or the same cell under different conditions, but the absolute amounts 
taken up will also vary. 

From this we may understand why, although one blood bathes all 
the body tissues, one tissue is high in potassium while another is low, 
and while one takes up much calcium another refuses it almost entirely. 
It is for this reason that the spinal cord takes up relatively more strychnin 
than any other tissue in the body, that anesthetics go into the central 
nervous system, that tetanus toxin picks out chiefly the peripheral nerves, 
that when any “vital” stain is introduced into the body only certain tis¬ 
sues are deeply stained, that when arsphenamine is given intravenously it is 
taken up chiefly by the (cells of the) spirochaetes, and to their destruc¬ 
tion. A specific poison, like a specific cure, becomes known to us when¬ 
ever we discover some substance which, when offered the healthy or dis- 


56 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 

eased human body, distributes itself in such a way between the various 
(colloidal) phases that make up the human body as to appear in a toxic 
concentration in the cell or organ under consideration before it does 
this in any other or all the other cells or organs of the body. 

It is well here to emphasize again the fact that intoxication at all 
times depends upon the concentration of the toxic substance present, and 
not upon the absolute amount given. The whole principle of detoxication 
depends upon the recognition and use of this fact. We can easily illus¬ 
trate what we mean when we discuss the intoxication that goes with any 
acute infection. Here we have an organism producing a poison at a 
fairly uniform rate. Where we do not possess a specific therapy much 
of the art and science of treatment consists in keeping the concentration 
of this toxic substance as low as possible. How do we manage this? 
When we cannot influence the factor of toxin production, we have only 
one way at our disposal, and that is to keep the concentration of the 
toxins as low as possible. To do this we can do but one thing, namely, 
give water. 

As we noted above, the giving of water makes for a secretion of 
water, and this secretion of water is necessary before we can get a secre¬ 
tion (washing out) of any toxic substance. By washing the toxic sub¬ 
stances out of the kidney cells, for example, we break down the equilib¬ 
rium existing between the toxic substance here and that in the blood. 
So more toxic substance will move from the blood over into the kidney 
to be eliminated if the third phase is created by giving water. But 
when the toxic concentration in the blood falls, the toxins from the cells 
will move over into the blood, and the lower we can keep the toxic 
concentration in the cells the less the intoxication and consequent patho¬ 
logical effect upon them. Now we also see the sense of giving water not 
only in a haphazard way as the patient may desire it, but in specified doses 
at regular intervals day and night. Otherwise during the periods of 
water abstention the toxin concentration will run up. What happens is 
illustrated by the variation in the concentration of the normal constitu¬ 
ents eliminated in the urine in any twenty-four hours. Since we are 
accustomed to consume most water with our meals, the urine after our 
meals is pale and low in urinary constituents. It is deep-colored and 
highly concentrated on rising in the morning, for through the night we 
do not consume any water. 


OSMOSIS AND QUESTION OF CELLULAR “MEMBRANES” 

In our analysis in physicochemical terms of certain phenomena famil¬ 
iar to every worker in the art and practice of medicine, we have almost 
ignored the much-discussed question of osmotic pressure. We have not 


OSMOSIS AND QUESTION OF CELLULAR “MEMBRANES” 57 


done this unthinkingly, hut because we feel that all those phenomena 
which are usually discussed under the heading of the osmotic phenomena 
of cells can more easily and more satisfactorily be explained on the 
basis of the colloidal constitution of living matter; and because we feel 
that the great mass of facts which has stood against the general appli¬ 
cability of the laws of osmotic pressure to cells can also be better ex¬ 
plained on the colloidal basis. We see no reason, therefore, for calling 
upon a complicated osmotic system for further help. But this point 
of view is not yet generally accepted in the biological sciences, and so 
we wish to summarize briefly some of the experimental and theoretical 
evidence usually adduced in favor of the osmotic conceptions of the ab¬ 
sorption of water and dissolved substances in the body, examine it criti¬ 
cally, and then briefly indicate how this may be used to better advantage 
in support of our colloidal conceptions of absorption. 

The widely divergent and contradictory “osmotic” conceptions of ab¬ 
sorption and secretion as upheld by different workers at the present time 
had their beginning in the original osmotic investigations of DeVries and 
Pfeffer. In order to account for the “turgor” (that is, water content) 
of plant cells, these authors held that the individual cells were sur¬ 
rounded by “osmotic” “membranes” of such a character that, while they 
allowed water to pass through them, they did not permit substances 
dissolved in this water to pass through. On this basis they explained 
the observation that plant cells swell up in water low in dissolved sub¬ 
stances, and shrink in more concentrated solutions, by saying that in 
the former case water is sucked into the cell, while in the latter it is 
sucked out. The movement of water into and out of the cell occurs 
until the (osmotic) concentration of dissolved substance is the same 
on both sides of the membrane postulated to exist about the cells. But, 
in order to permit the water to move, this membrane must be impermeable 
to dissolved substances (otherwise, of course, the dissolved substances 
would simply move from a region of higher concentration to one of 
lower concentration, and so osmotic differences could not come to pass, 
and consequently there would be no movement of water). 

From these observations and theoretical views sprang the interest 
of the physical chemists in the whole problem of osmosis and so we see 
constructed the various “osmotic cells 9 that may be seen in any physico¬ 
chemical laboratory. Pfeffer was again pioneer here. He conceived the 
idea of supporting the “precipitation membranes” that Moritz Traube 
had described before him in the walls of a porous pot, in order to give 
them enough strength to withstand considerable pressure. Such “precipi¬ 
tation membranes” may be produced by the use of many different sub¬ 
stances, but the best and commonest one is made by allowing the solution 
of a copper salt and the solution of a ferrocyanid to move into the wall 
of a porous pot from opposite sides. They meet in the wall of the pot 


58 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


and a precipitate of copper ferrocyanid is deposited here. The copper 
solution may now be washed out of the pot and the ferrocyanid rinsed 
off the outside. In the wall of the pot remains a “precipitation mem¬ 
brane” of copper ferrocyanid. This membrane allows water to pass 
through it easily, but it will not allow substances dissolved in this water 
to get through. The membrane is “semipermeable,” and therefore is 
identical in this property with the “osmotic” membrane that Pfeffer 
maintained surrounded the living cell. If the laboratory cell is filled 
with a solution of any kind, and is then placed in water, water is sucked 
into the cell; if it is placed instead in a more concentrated solution, 
water is sucked out of the cell. As is readily apparent, this corre¬ 
sponds to what Pfeffer and DeVries observed in the case of the living 
cell. 

Pfeffer made many osmotic measurements with his laboratory cell, 
and, on the basis of his observations, van’t Hoff some years later formu¬ 
lated his famous laws, which are as follows: 

1. At constant temperature the osmotic pressure of dilute solutions 
is proportional to the concentration of the dissolved particles. 

2. At the same temperature equal volumes of all dilute solutions 
having the same osmotic pressure contain the same number of dissolved 
particles. 

3. At constant volume the osmotic pressure of any solution varies 
directly as the absolute temperature. 

The work and conclusions of van’t Hoff and the physical chemists 
now became retroactive, and the attempt was made to apply the laws of 
van’t Hoff not only to the biological facts that DeVries and Pfeffer had 
furnished, but to the additional ones contributed by Hamburger, Gryns, 
Koeppe, Loeb, Hober, Overton, Webster, etc. To this end the observa¬ 
tions made on plant and animal cells were compared with those made 
with the laboratory osmotic cell. When a solution of any electrolyte 
or non-electrolyte was found not to change the volume of liquid in an 
osmotic cell, it was said to be “isosmotic” with the cell contents. Equally 
concentrated solutions of all kinds were found to be isosmotic with the 
contents of the osmotic cell. These were, therefore, isosmotic with each 
other. When a solution of any kind was found not to change the volume 
of any living cell it was said to be “isotonic” with the contents of this 
cell. In this way the solutions of many different substances were com¬ 
pared and the “isotonic coefficients” determined in each case. If the 
laws of osmotic pressure were active in living protoplasm, it was there¬ 
fore to be expected that, if certain solutions were “isotonic” with each 
other, they should also be “isosmotic” with each other. 

When the first rough comparisons were made it was in fact thought 
that the isotonic solutions were isosmotic, but this conclusion could not 
stand the pressure of more careful and more numerous observations. 


OSMOSIS AND QUESTION OF CELLULAR “MEMBRANES” 59 


To-day we may safely say that we do not know a single cell for which 
the laws of osmotic pressure are valid. 

We need not go into details to prove this. If cells obeyed the laws of 
osmotic pressure, then they ought always to have the same volume in 
isosmotic solutions of different substances. Exceptions to this conclusion 
are the rule. Again, with every increase in the concentration of the 
medium surrounding a cell we should get a proportional decrease in 
the volume of the cell. As a matter of fact, the shrinkage is always 
less than anticipated (Koeppe, Durig). While electrolytes and non-elec¬ 
trolytes are in our laboratory osmotic cells equally active when the same 
number of dissolved particles are present in the unit volume, this is not 
the case in living cells. Generally speaking, the electrolytes are active 
out of all proportion to the non-electrolytes when living cells are con¬ 
cerned. How all these facts are readily explained on the colloidal basis 
has been pointed out above. 

To have the laws of osmotic pressure tenable for living cells we must 
have semipermeable membranes about them. Only as this is the case can 
changes in osmotic pressure become available for the movement of water 
into and out of cells. If, for the sake of argument, we grant this conclu¬ 
sion, then no dissolved substances can get into or out of the cell. Such 
a conception of the cell is impossible, for, under such circumstances, 
how could a cell get its necessary food, or how could it rid itself of its 
various metabolic products ? To get around this difficulty various ob¬ 
servers have made these osmotic membranes permeable to some or many 
dissolved substances. But the moment we grant this we can no longer 
maintain differences in osmotic pressure, and so water can no longer be 
absorbed. The adherents to the view that “osmotic” membranes exist 
about cells can take their choice: either they can utilize their conception 
in order to make water move, or they can have these membranes perme¬ 
able and so have dissolved substances move—but they cannot have both. 

An enormous literature has sprung up about this question of “mem¬ 
branes” surrounding cells. From the original osmotic membranes of 
Pfeffer which were semipermeable, we have come to those which are 
partially permeable, and then to those which are permeable sometimes 
and then again not. But even these complicated notions encounter trouble, 
for there is so little connection between the kind of substances that enter 
cells and those that do not. Only the members of one group—that which 
has a ready solubility in the fats—have been recognized as having one 
property in common, and to account for their ready entrance into cells the 
osmotic membrane about cells has been endowed with lipoidal character¬ 
istics. The unfortunate part about this theory, which is in essence that 
of E. Overton, is that, while it renders easier our conception of the ab¬ 
sorption of these lipoid-soluble substances, it makes it impossible to get 
the ordinary salts and water into cells, for these are not particularly 


60 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


soluble in the lipoids. And yet we know from physiological and patho¬ 
logical facts that both must be able to get into cells. 

Moreover, what do we gain when we have succeeded in getting some 
dissolved substance or water through any membrane postulated to exist 
about a cell? It would collect here and we should still have to account 
for the movement of either the dissolved substance or the water into or 
through the rest of the cell protoplasm. There are no membranes about 
cells, neither of the lipoid type (Durig, Pauli, Fischer), nor of the 
“osmotic” type (Fischer). All the phenomena which offer so much 
difficulty in explanation when we assume that membranes exist about 
cells are readily interpreted, without recourse to such postulates, on 
the basis of the colloidal constitution of protoplasm as we indicated above. 

In answer to these arguments some of our critics have retorted that 
a “membrane” exists wherever two phases come in contact with each 
other. At this point we have to stop and begin to define terms, for 
here the arguments begin to become academic. A drop of any fluid, a drop 
of any colloidal solution, a drop of protoplasm or a cell, has a “mem¬ 
brane” about it, but this “membrane” is simply a surface tension film; 
it has nothing in common with the “osmotic membranes” that are in 
turn talked about by the botanists, the physical chemists, and the original 
animal physiologists who worked in this field. These surface tension 
films are chemically identical with the rest of the cell protoplasm, and 
(except as colloidal particles tend to collect in these surface films and so 
raise the concentration of these particles here) as such behave toward 
water or dissolved substances exactly as does the rest of the cell proto¬ 
plasm. 

We encounter differences in the absorption of water and of dissolved 
substances in the living animal as we pass from one (colloidal) phase to 
another. Such different phases may be represented by different organs, 
different tissues, different cells or intercellular substances, different parts 
of the same cells. If such phase differences are ultimately shown to exist 
at the surface of cells, they will assume an importance in this problem 
of absorption and secretion. But this importance will be neither greater 
nor different in this problem, because the phase difference occurs at the 
surface of the cell, than if it had occurred anywhere else in that colloidal 
complex that we call living matter. 

The following bibliography is necessarily most incomplete, but the 
easily accessible references here given will readily put any one who con¬ 
sults them and who so desires in touch with the voluminous literature 
now available on these subjects. 


REFERENCES 


61 


REFERENCES 

General articles such as this are bound to partake of the personal views 
of the' author. For excellent general articles on physicochemical 
views in pharmacology and therapeutics, written for the most part 
from quite a different point of view, see: 

Bechhold, H. Die Kolloide in Biologie nnd Medizin, 333, Dresden, 

1912. 

Hamburger, H. J. Osmotischer Druck und Ionenlehre, ii, 92, 166; iii, 
222, Wiesbaden, 1904. 

Hober, Rudolf. Koranyi-Richter’s Physikalische Cbemie und Medizin, i, 
295, Leipzig, 1907. 

Physikalische Chemie der Zelle und der Gewebe, dritte Auflage, 
Leipzig, 1911. 

Overton, E. Nagel’s Handb. d. Physiol., ii, 744, Braunschweig, 1907. 

Spiro, K. Koranyi-Richter’s Physikalische Chemie und Medizin, ii, 225, 
Leipzig, 1908. 

-Oppenheimer’s Handb. d. Biochem., ii, Erster Teil, 1, Jena, 1910. 

Starling, Ernest H. Oppenheimer’s Handb. d. Biochem., iii, Zweiter 
Teil, 25, Jena, 1910. 

The best general text available on colloids and their properties is: 

Ostwald, Wolfgang. Grundriss der Kolloidchemie, zweite Auflage, Dres¬ 
den, 1911. 

See also: 

Freundlich, H. Kapillarchemie, Leipzig, 1909. 

Muller, Arthur. Allgemeine Chemie der Kolloide, Dresden, 1907. 

Poschl, Viktor. Einfuhrung in die Kolloidchemie, dritte Auflage, Dres¬ 
den, 1911. 

Svedberg, The. Kolloide Losungen anorganischer Stoffe, Dresden, 1909. 

Zsigmondy. Colloids and the Ultramicroscope, translated by Jerome 
Alexander, New York, 1909. 

The last-mentioned two volumes deal chiefly with inorganic colloids. 

In addition to these general texts, articles dealing with all phases of 
colloid chemistry, both theoretical and practical, may be found in 
the following periodicals: 

Kolloidchem. Beihefte, Dresden; Ztschr. f. Chem. u. Indust. d. Kolloide 
[“Kolloid-Ztschr.”], Dresden. 

Shorter general accounts of colloids and changes in their state may 
be found in: 




62 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


Bechhold, H. Hie Kolloide in Biologie nnd Medizin, 1 and 118, Dres¬ 
den, 1912. 

Findlay, Alexander. Physical Chemistry, 62, London, 1905. 

Fischer, Martin H. Physiology of Alimentation, 250, New York, 1907. 

-Edema, 18, New York, 1910. 

Hober, Rudolf. Physikalische Chemie der Zelle und der Gewebe, zweite 
Auflage, 197, Leipzig, 1906. 

Loeb, Jacques. Proteins and the Theory of Colloidal Behavior, New York, 
1920. 

Michaelis, Leonor. Koranyi-Richter’s Physikalische Chemie und Medizin, 
ii, 341, Leipzig, 1908. 

Ostwald, Wolfgang. Oppenheimer’s Handb. d. Biochem., iii, 840, Jena, 
1909. 

The crystalloids are discussed chiefly in the excellent textbooks available 
on physical chemistry. The following are standard works: 

Cohen, Ernst. Physical Chemistry for Physicians and Biologists, trans¬ 
lated by M. H. Fischer, New York, 1903. 

Ereundlich, Herbert. Kapillarchemie, 309, Leipzig, 1909. 

Hober, Rudolf. Physikalische Chemie der Zelle und der Gewebe, 19, 
Leipzig, 1902. 

Jones, Harry C. Elements of Physical Chemistry, New York, 1902. 

Nernst, Walter. Theoretical Chemistry, translated by H. T. Tizard, 
London, 1911. 

Noyes, A. A. Journ. Am. Chem. Soc., xxvii, 85 (1905). 

Ostwald, Wilhelm. Principles of Inorganic Chemistry, translated by 
Alexander Findlay, New York, 1904. 

Ostwald, Wolfgang. Kolloid-Ztschr., i, 291 and 331, 1907. 

-Grundriss der Kolloidchemie, zweite Auflage, Dresden, 1911. 

Perrin, J. Journ. de chim. phys., iii, 50, 1905. 

See the textbooks of physical chemistry cited. See also: 

Bence, Julius. Koranyi-Richter’s Physikalische Chemie und Medizin, 
ii, 1, Leipzig, 1908. 

Cohen, Ernst. Physical Chemistry for Physicians and Biologists, trans¬ 
lated by M. H. Fischer, New York, 1903. 

Findlay, Alexander. Physical Chemistry and Its Applications in Medical 
and Biological Science, London, 1905. 

Fischer, Martin H. Edema, 184, New York, 1910, where references 
to earlier work will be found. 

-Kolloidchem. Beihefte, ii, 304, 1911. 

--Nephritis, 102, 193, New York, 1912. 

Hamburger, H. J. Osmotischer Druck und Ionenlehre, i, 1, Wiesbaden, 
1902. 






REFERENCES 


63 


Hober, Rudolf. Physikalische Chemie der Zelle und der Gewebe, zweite 
Auflage, 71, Leipzig, 1906. 

Hogan, James J. and Fischer, Martin H. Kolloidchem. Beihefte, ii, 1912. 

Jones, Harry C. The Theory of Electrolytic Dissociation and Some of 
Its Applications, Hew York, 1900. 

Kanitz, A. Oppenheimer’s Handb. d. Biochem., i, 26, Jena, 1909. 

The matter of equilibrium is discussed in detail, with numerous examples, 
in any of the larger textbooks of physical chemistry. Especially 
good is: 

Ostwald, Wilhelm. Fundamental Principles of Chemistry, 60, translated 
by H. W. Morse, Hew York, 1909. 

For a discussion of the nature of the combination existing between oxygen 
and hemoglobin, see: 

Arrhenius, Svante. Ztschr. f. physik. Chem., i, 296, 1887; x, 51, 1892. 

Bechhold and Ziegler. Ibid., lvi, 105, 1906. 

Hober, R. Physikalische Chemie der Zelle und der Gewebe, zweite 
Auflage, 318, Leipzig, 1906. 

Meyer, Kurt. Hofmeister’s Beitr., vii, 393, 1906. 

Ostwald, Wolfgang. Kolloid-Ztschr., ii, 264 and 294, 1907. 

Roth. Engelmann’s Arch., 416, 1899. 

Stoffel, Fritz. Dissertation, Zurich, 1908. 

See also: 

Berthelot and Jungfleisch. Ann. Chem. Phys., xxvi, 396, 1872. 

Liesegang, R. E. Chemische Reaktionen in Gallerten, 1898. 

• -Ztschr. f. physik. Chem., 1907. 

Meyer, Hans. Arch. f. exper. Path. u. Pharmakol., xlii, 109, 1899: 
xlvi, 338, 1901. 

Michaelis, L. Koranyi-Richter’s Physik. Chem. u. Medizin, ii, 341, 
Leipzig, 1908. 

Ostwald, Wilhelm. Lehrb. d. allg. Chem., zweite Auflage, ii, iii, 1905. 

Ostwald, Wolfgang. Grundriss der Kolloidchemie, Dresden, 1911. 

Overton, E. Studien iiber die Harkose, 1901. 

--Vierteljahresehr. d. naturf. Gesellsch. zu Zurich, xl, 1, 1895; xli, 

383, 1896; xliv, 88, 1899. 

-Ztschr. f. physik. Chem., xxii, 189, 1897. 

• -Pfliiger’s Arch., xlii, 261, 1902. 

Pauli, Wolfgang. Physical Chemistry in the Service of Medicine, 94, 
translated by M. H. Fischer, Hew York, 1907. 

Robertson, T. B. Journ. Biol. Chem., iv, 35,1908. 

Van Slyke, D. D. and Van Slyke, L. L. Am. Chem. Journ., xxxviii, 
383, 1907. 

■-Journ. Biol. Chem., iv, 259, 1908. 







64 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


These articles will serve as a guide to the extensive literature available 
on this subject . 

See for example: 

Dreser, H. Arch f. exper. Path. u. Pharmakol., xxxii, 456, 1893. 
Ehrlich, Paul. Sauerstoif-Bediirfniss des Organismus, Leipzig, 1885. 

-Collected Studies on Immunity, translated by Bolduan, New 

York, 1907. 

-Deutsche med. Wchnschr., 597, 1898. 

Fischer, Martin H. Nephritis, 115, New York, 1912. 

Griitzner. Pfliiger’s Arch., Iviii, 69, 1894. 

Harvey, E. N. Science, N. S., xxxii, 565, 1910. 

-Journ. Exper. Zool., viii, 355, 1910; x. 507, 1911. 

Heald. Botanical Gazette, xxii, 125, 1896. 

Hober, Rudolf. Pfliiger’s Arch., ci, 627, 1904; cii, 196, 1904. 

-Biochem. Zentralbl., vii, 656, 1908. 

-Biochem. Ztschr., xix, 494, 1909; xx, 56, 1909. 

Kahlenberg and True. Botanical Gazette, xxii, 81, 1896. 

Lillie, Ralph. Biol. Bull., xvii, 3, 1909. 

-Am. Journ. Physiol., xxiv, 14, 1909; xxvii, 289, 1911. 

Loeb, J. Pfliiger’s Arch., lxix, 1, 1897; lxxi, 457, 1898. 

Lyon, E. P. Science, N. S., xxxii, 249, 1910. 

Mathews, A. P. Am. Journ. Physiol., xii, 455, 1904; xii, 419, 1905; 
xv, 492, 1902. 

McClendon, J. F. Ibid., xxvii, 240, 1910. 

Meyer, Hans. Arch. f. exper. Path. u. Pharmakol., xlii, 109, 1899; 
xlvi, 338, 1901. 

Nathanson, A. Jahrb. f. wissensch. Botanik, xxxviii, 241, 1902; xxxix, 
607, 1904; xl, 403, 1904. 

Osterhout, W. J. Y. Botanical Gazette, xlvi, 53, 1908. 

Overton, E. Studien liber die Narkose 1901. 

-Vierteljahreschr. d. naturf. Gesellsh. zu Zurich, xl, 1, 1895; xii, 

383, 1896; xliv, 88, 1899. 

-Ztschr. f. physik. Chem., xxii, 189, 1897. 

-Pfliiger’s Arch., xlii, 261, 1902. See also: Jahrb. f. wissensch. 

Botanik, xxxiv, 669, 1900. 

Paul and Kronig. Ztschr. f. physikal. Chem., xxi, 414, 1896. 

Pelet-Jolivet, L. Die Theorie des Farbeprozesses, Dresden, 1910. 

Pfeffer, W. Osmotische Untersuchungen, Leipzig, 1877. See also: 
Traube, M. Arch. f. Anat. u. Physiol., 87, 1867; Zangger, Heinrich. 
Ergebn. d. Physiol., vii, 99, 1908. In this paper extensive references 
to the literature dealing with membranes will be found. 

Richards. Am. Chem. Journ., xx, 121, 1898. 

Sheurlen and Spiro. Munchen. med. Wchnschr., xliv, 81, 1897. 











REFERENCES 


65 


True. Botanical Gazette, xxvi, 407, 1898. See also: Clark. Ibid., 
xxviii, 289, 1899; Stevens. Ibid., xxvi, 377, 1898. 

Zangger, Heinrich. Vierteljahreschrift d. naturforsch. Gesellsch. in 
Zurich, liii, 408, 1908. 

In this connection see for example: 

(On the heart ) : 

Benedict, Stanley R. Am. Joum. Physiol., xiii, 192, 1905; xxii, 16, 
1908. 

Garrey, W. E. Ibid., iii, 291, 1900; xiii, 186, 1905. 

Green, Charles W. Ibid., ii, 82, 1898. 

Howell, Wm. H. Ibid., ii, 47, 1898. 

Lingle, D. J. Ibid., iv, 265, 1900; viii, 75, 1902. 

(On muscle) : 

Collected papers in Decennial Publications, Univ. Chicago, 1903. 

Loeb, J. Festschr. f. Fick, 101, 1899. 

-Am. Journ. Physiol., iii, 327 and 383, 1900. 

(On ion protein compounds) : 

Pauli, Wolfgang. Anz. d. kaiserl. Akad. d. Wissensch., xxiv, 262, 1899. 

-Uber physikalisch-chemische Methoden und Probleme in der 

Medizin, Vienna, 1900. Available in English in Physical Chemistry 
in the Service of Medicine, translated by Fischer, Hew York, 1907. 

For general discussions of this subject see: 

Ostwald, Wolfgang. Grundriss der Kolloidchemie, zweite Auflage, Dres¬ 
den, 1911. 

See also: 

Fischer, Martin H. Physiology of Alimentation, 268, 182-187, 267-269, 
Hew York, 1907. 

• -Journ. Am. Med. Ass., Ii, 830, 1908. 

• -Kolloidchem. Beihefte, i, 93, 1909. 

-Edema, Hew York, 1910, where references to his earlier work 

may be found. 

--Pfluger’s Arch., cxxv, 99, 396, 1908; cxxvii, 46, 1909. 

--Kolloid-Ztschr., viii, 159, 1911, or Hephritis, 61, Hew York, 1912. 

Fischer, Martin H. and Moore, Gertrude. Am. Journ. Physiol., xx, 330, 
1907. 

-Kolloid-Ztschr., v, 197, 1909. 

_Pfluger’s Arch., cxxv, 99, 1908. See also: Proctor, H. R. Kolloid- 

Ztschr., iii, 85, 1910 (original not accessible) ; Pauli, Wolfgang and 
Handovsky, H. Biochem. Ztschr., xviii, 340, 1909; xxiv, 239, 1910; 
Gedroiz, K. Russ. Journ. f. exper. Landwirtschaft, xi, 66, 1910. 

Gies, Wm. J. Journ. Biol. Chem., ii, 489, 1907. 











66 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


Handovsky, H. Fortschritte in der Kolloidchemie der Eiweisskorper, 
Dresden, 1911, where references to his earlier papers may be found. 
See also: Handovsky and Wagner, R. Biochem. Ztschr., xxxi, 32, 
1911; Porges und Neubauer. Ibid., xvii, 152, 1907. 

Hardy, W. B. Joum. Physiol., xxiv, 288, 1899 ; xxxiii, 251, 1905. 

-Proc. Roy. Soc. London, Series B, lxxix, 413, 1907. 

-Ztschr. f. physik. Chem., xxxiii, 385, 1900. 

Hofmeister, F. Arch. f. exper. Path. u. Pharmakol., xxvii, 395, 1890; 
xxviii, 210, 1891. 

Ostwald, Wolfgang. Grundriss der Kolloidchemie, Leipzig, 1911. 

-Pfluger’s Arch., cvi, 586, 1905 ; cviii, 563, 1905. 

-Kolloid-Ztschr., ii, 264 and 294, 1908; vi, 297, 1910. 

Pauli, Wolfgang. Physikalisch-chemische Methoden und Probleme in der 
Medizin, Vienna, 1900. Available in English in Physical Chemistry 
in the Service of Medicine, translated by Martin H. Fischer, New 
York, 1907. 

-Pfluger’s Arch.,, lxvii, 219, 1897; lxxi, 1, 1898. 

-Hofmeister’s Beitr., numerous papers during the years 1902 to 

1908. 

-Biochem. Ztschr., xvii, 235, 1909; xviii, 340, 1909; xxiv, 239, 

1910. 

A general statement of his views is found in Kolloid-Ztschr., vii, 241, 
1910. 

Schorr, K. Cited by Pauli and Handovsky. 

Schroeder, P. von. Ztschr. f. physik. Chem., xlv, 75, 1903. 

Spiro, K. Hofmeister’s Beitr., iv, 300, 1903. 

- Ibid, v, 276, 1904. 

Strietmann, Wm. H. and Fischer, Martin H. Kolloid-Ztschr., 1912. 

In this connection see: 

Moore and Roaf. Biochem. Journ., iii, 55, 1908. 

Roaf, H. E. Quart. Journ. Exper. Physiol., iii, 75, 1910. 

For studies on the viscosity of the circulating blood see: 

Bechhold, H. Kolloide in Biologie und Medizin, 240, Dresden, 1912. 
Bechhold, H. and Ziegler, J. Ztschr. f. physik. Chem., xvi, 257, 1907. 
Burton-Opitz, R. Pfluger’s Arch., lxxxii, 447, 1900; cix, 359, 1907. 
Determann. Ztschr. f. klin. Med., lix, 283 1906. 

Ferrai. Arch, di fisiol., i, 305, 1904. 

Gudzent, F. Ztschr. f. physiol. Chemie, lxiii, 455, 1909. 

Hurthle and Burton-Opitz. Pfluger’s Arch., lxxxii, 415, 1900. 

Lichtwitz. Deutsche med. Wchnschr., xxxvi, 704, 1910. 

Liesegang, R. E. Beitr age zu einer Kolloidchemie des Lebens, Dresden, 

1909. 










REFERENCES 


67 


Pauli, Wolfgang. Naturw. Rundschau, xxi, 3, 1906. 

' Physical Chemistry in the Service of Medicine, 136, translated 

by M. H. Fischer, New York, 1907. 

Pauli, Wolfgang and Handovsky, H. Biochem. Ztschr., xviii, 1909. 
Pauli, Wolfgang and Samec, M. Ibid., xvii, 235, 1909. 

Schade, H. Kolloid-Ztschr., iv, 175, 1909. 

-Kolloidchem. Beihefte, i, 375, 1910. 

Wells, H. Gideon. Arch. Int. Med., vii, 721, 1911. 

A general discussion of the problems involved is found in: 

Fischer, Martin H. Edema, New York, 1910. 

-Nephritis, New York, 1912; see also Kolloidchem. Beihefte, ii, 

304, 1911. 

Hogan, J. J. and Fischer, Martin H. Kolloidchem. Beihefte, 1912. In 
these articles will be found numerous references to earlier papers. 

See also: 

Bechhold, H. Kolloide in Biologie und Medizin, 196, 293, Dresden, 1912. 

Classical articles presenting older and different views, with numerous 
references to the literature bearing on these questions, are found in: 

Cohnheim, O. Nagel’s Handb. d. Physiol., ii, 607, Braunschweig, 
1907. 

Hamburger, H. J. Osmotischer Druck und Ionenlehre, ii, 93, Wiesbaden, 
1904. 

Heidenhain, R. Hermann’s Handb. d. Physiol., v, Leipzig, 1883. 

Hober, R. Koranyi-Richter, Physik. Chem. u. Medizin, i, 295, Leipzig,* 
1907. 

Hofmeister, F. Arch. f. exper. Path. u. Pharmakol., xxviii, 210, 1891. 
Overton, E. Nagel’s Handb. d. Physiol., ii, 774, Braunschweig, 1907. 
Reid, E. Waymouth. Schaefer’s Textbook of Physiology, i, 261. 
Starling, E. H. Ibid., i, 285. 

■-Oppenheimer’s Handb. d. Biochem., iii, 206, Jena, 1909. 

See also in this connection: 

Auer, John. Am. Journ. Physiol., xvii, 15, 1906. 

Bancroft, Frank W. Journ. Biol. Chem., iii, 191, 1907. 

MacCallum, J. B. Univ. Calif. Pub., i, 1904. 

-Am. Journ. Physiol., x, 101, 1904. 

-Pfliiger’s Arch., civ, 421, 1904. 

See the fundamental investigations of: 

Crile, George W. Surgical Shock, Philadelphia, 1899. 

Henderson, Yandell. Am. Journ. Physiol., xxi, 148, 1908; xxiv, 66, 
1909; xxv, 310 and 385, 1910; xxvii, 167, 1910. 

Hogan, James J. and Fischer, Martin H. Kolloidchem. Beihefte, 1912. 








68 SOME PHYSICOCHEMICAL PRINCIPLES IN THERAPY 


Mendel, Lafayette B. Centralbl. f. d. ges. Physiol, u. Path. d. Stoff- 
wechsels, ix, 641, 1908. 

Saiki, T. Journ. Biol. Chem., ii, 251, 1906. 

See in this connection the fundamental Studies of Wolfgang Ostwald, 
according to whom the poisonous effects of any solution may be 
expressed mathematically: 

Frey. Pfliiger’s Arch., cxx, 60-136 (three papers), 1907. 

Haake, B. and Spiro, K. Hofmeister’s Beitr., ii, 149, 1902. 

Limbeck, von. Arch. f. exper. Path. n. Pharmakol., xxv, 89, 1888. 
Magnus. Ibid., xliv, 68 and 396, 1900. 

-IJber Diurese, Heidelberg, 1900. 

Ostwald, Wolfgang. Pfliiger’s Arch., cxx, 19, 1907. 

-Kolloid Ztschr., ii, 108 and 138, 1907. 

Ostwald, Wolfgang and Dernoschek, A. Ibid., vi, 24)7, 1910. 

Sollman, Torald. Arch. f. exper. Path. u. Pharmakol., xlvi, 13, 1901. 

See in connection with this problem: 

Bechhold, H. Kolloide in Biologie und Medizin, 28, Dresden, 1912. 
Goppelsroeder. Kolloid-Ztschr., iv, 23, 94, 191, 236, 312, 1909. 
Henderson, L. J. Ergebn. d. Physiol., viii, 254, 1909. 

Van Bemmelen, J. M. Die Absorption, 445, Dresden, 1910. 

For an interesting list of such conditions see: 

Durig. Pfliiger’s Arch., 1902-1903. 

Fischer, Martin H. Physiology of Alimentation, 182-187, 267-269, New 
York, 1907. 

-Pfliiger’s Arch., cxxv, 99, 1908; cxxiv, 69, 1908; cxxv, 396, 1908; 

cxxv, 21, 1909. 

--Journ. Am. Med. Ass., Ii, 830, 1908. 

Fischer, Martin H. and Moore, Gertrude. Am. Journ. Physiol., xx, 330, 
1907. 

-Kolloid-Ztschr., v, 197, 286, 1909. 

Pauli, Wolfgang. Sitzungsb. d. Wien. Akad., cxiii, 38, 1904. 

Salant, William. The Action of Drugs Under Pathological Conditions, 
U. S. Dept. Agriculture, Bureau of Chemistry, Circular No. 81, 

1911. 







CHAPTER II 


NUTRITION AND DIETETICS 
Warren Coleman 
Revised by Erwin G. Gross 

Some knowledge of the laws of nutrition, as well as of dietetics, is 
requisite for the rational construction of dietaries, whether they he in¬ 
tended for persons in health or for those ill from disease. 

Nutrition concerns the digestion and absorption of foods, the destinies 
and transformations of the foodstuffs after absorption, and the energy 
liberated within the body by their oxidation. 

Dietetics, on the other hand, relates to the selection of foods, the 
arrangement of dietaries which cover the nutritive requirements and, at 
the same time, conform to the likes, dislikes, and idiosyncrasies of persons, 
and the methods of preparing and serving the food. 

A knowledge of the fuel values of foods is likewise essential to rational 
feeding. The body derives energy from food in much the same manner 
that an engine does from coal. The universal law of the conservation of 
energy holds for the body as well as for the engine; that is, the body de¬ 
velops through oxidation a definite amount of energy from a known 
quantity of food. Since the total energy which the body requires for the 
performance of its functions is accurately known, the fuel values of all' 
diets should be carefully adjusted to the patient’s needs. 

No attempt will be made to discuss here the dietetic treatment of the 
different diseases. Dor such details the reader is referred to the appro¬ 
priate chapters. The purpose of this chapter is to furnish simply the 
information with the aid of which diets may be arranged for any disease. 


FOODS 

Voit defines a food as a palatable mixture of foodstuffs which is 
capable of maintaining the body in an equilibrium of substance, or capable 
of bringing it to a desired condition of substance. The ideal food is a 
palatable mixture of foodstuffs arranged together in such proportion as to 

69 


70 


NUTRITION AND DIETETICS 


burden the organism with a minimum amount of labor. It should be 
added that the vitamin content of the food must be unimpaired. 

Foodstuffs 

Practically all of our foods, as ordinarily served, are mixtures of food¬ 
stuffs. A foodstuff is a material capable of being added to the body’s 
substance, or one which when absorbed into the blood-stream will prevent 
or reduce the wasting of a necessary constituent of the organism 
(Lusk). 

Foodstuffs are classified as follows: (1) proteins; (2) carbohydrates; 
(3) fats; (4) vitamins; (5) inorganic substances. 

Proteins. —Proteins may be defined as complex organic compounds of 
high molecular weight made up of carbon, hydrogen, oxygen, nitrogen, 
sulphur, and sometimes containing phosphorus and iron. Protein contains 
nitrogen in a form available for the physiological needs of the organism, 
and this differentiates it from other foodstuffs. Considered from a 
chemical standpoint proteins consist wholly, or in part, of amino-acids 
united by their carboxyl and amino groups. 

Proteins are found in nature in living matter, or associated with it, 
and always produced by it. They comprise gliadin, casein, egg-albumin, 
gluten, edestin, etc. 

Carbohydrates. —Carbohydrates are abundant in the plant kingdom, 
forming the chief mass of the dry substance of the plant structure. In 
animal tissue they are found in small quantities either in a free condition 
or in combination with nitrogenous substances. The carbohydrates are 
the chief source of energy to the body and therefore are of great impor¬ 
tance in nutrition. They contain the elements carbon, hydrogen and 
oxygen; the last two elements are usually in the ratio of 2:1, but not all 
compounds having this ratio are carbohydrates as (CH 3 COOH) acetic 
acid. 

It is difficult to give an exact definition of carbohydrates, however 
chemically they may be defined as aldehyds or ketones of the polyhydric 
alcohols. The carbohydrates are generally divided into three groups : 
monosaccharids such as dextrose and levulose; disaccharids such as 
sucrose, maltose, and lactose; and polysaccharids such as starch, dextrin, 
and cellulose. The ending “ose” is given to the monosaccharids and 
disaccharids according to the number of carbon atoms contained in the 
molecule. Thus, one speaks of a pentose CgH^Og, or a hexose C 6 H 12 0 6 , 
or a hexobiose C 12 H 22 O n . 

Fats. —Fats are distributed widely in both animal and plant kingdoms. 
In the latter they occur chiefly in the seeds, fruits, and in some instances 
in the roots. They occur in all animal tissues in varying quantity. 

Chemically the neutral fats are the glyceryl-esters of fatty acids. The 


USES OF FOODS 


71 


animal fats are chiefly mixtures of the esters of oleic, stearic and palmitic 
acid. The fat of milk contains, besides these, considerable amounts of 
the lower fatty acids, such as butyric, caproic, caprylic and capric acid. 
The triglycerids of linoleic, lauric, myristic, etc., are found in great abun¬ 
dance in the vegetable kingdom. 

In addition to the neutral fats, foods contain various fatlike sub¬ 
stances known as lipoids; some of these lipoid substances may have con¬ 
siderable importance in nutrition, but as yet we do not know their exact 
importance. Representatives of the lipoids are cholesterin and lecithin. 

Vitamins. —Vitamins are organic substances of unknown chemical con¬ 
stitution; they occur in small quantities in many foods, and are of the 
utmost importance in nutrition. 

Inorganic Substances. —The inorganic substances are water and the 
salts of sodium, potassium, magnesium, chlorin, sulphur, phosphorus, iron 
and iodin. 

Uses of Foods 

The chief functions of food are: (1) to yield energy, (2) to build 
tissue, (3) to regulate body processes. 

Uses of Proteins. —-Proteins are the only foodstuffs capable of supply¬ 
ing the nitrogenous needs of the body, while all the organic foodstuffs are 
capable of furnishing energy. Both vegetable and animal proteins are 
apparently equally serviceable in furnishing the nitrogenous needs. As 
a source of energy, protein, in amounts recommended by Voit and At¬ 
water, represents from 16 to 20 per cent of the total metabolism, and a 
lesser amount in the standard recommended by Chittenden. 

The protein molecule consists of about 50 to 60 per cent of a car¬ 
bonaceous group, or “carbon moiety” which is split off and oxidized, like 
carbohydrate, to carbon dioxid and water. In diabetes mellitus part 
or all of this, depending on the severity of the case, will appear in the 
urine as glucose. 

The nitrogen of protein taken in excess of the body’s needs is rapidly 
excreted, appearing in urine chiefly in the form of urea. There is a 
nitrogen retention in the body during growth, pregnancy and convales¬ 
cence from wasting diseases. 

Adequate and Inadequate Proteins .—Some proteins when fed, 
together with sufficient non-protein material, vitamins, water and salts, 
furnish all the nitrogenous compounds necessary for growth and main¬ 
tenance, others under the same conditions fail to support growth or 
maintenance or both. The former group may he called adequate pro¬ 
teins and the latter inadequate proteins. The difference in the two 
groups is in their “make-up” of amino-acids. While the body can syn¬ 
thesize many of the amino-acids which it uses, it apparently cannot syn¬ 
thesize certain ones which are necessary for maintenance and growth. 


72 


NUTRITION AND DIETETICS 


Gelatin is an inadequate protein, as, while it is readily digested and 
oxidized to carbon dioxid, water, and urea and yields energy, it is in¬ 
capable of maintaining the body in nitrogen equilibrium. Gelatin is 
deficient in tryptophan, tyrosin and cystin. Osborne and Mendel work¬ 
ing with other deficient proteins have come to the conclusion that the 
amino-acids, lysin, tryptophan and cystin are necessary as constructive 
units in growth, and that tryptophan and cystin are necessary for 
maintenance. 

Under practical conditions, however, we are not dealing with single 
purified proteins, since our common protein foods all contain mixtures 
of proteins. Thus any of the foods will furnish more than one protein. 
Osborne and Mendel have demonstrated that proteins will supplement 
each other. 

Uses of Carbohydrates.—Carbohydrates are the chief source of the 
body’s energy, whether expressed in the form of muscular work or in the 
form of heat. The carbohydrate of the food is transformed into glycogen 
and stored, principally in the liver and muscles, until needed. An excess 
of carbohydrate over the daily needs leads to more complete filling of the 
glycogen depots, or it is transformed into and stored as fat. The body 
has not, however, an unlimited tolerance for carbohydrate. If too much 
be taken, sugar appears in the urine, producing alimentary glycosuria. 
This is especially true for sugars. It has been stated that no amount of 
starch in the food can cause glycosuria, except in diabetics or those pre¬ 
disposed to the disease, because of its slow rate of absorption. 

Another function which carbohydrate serves is to spare protein. When 
neither carbohydrate nor fat is available, as in the late stages of starva¬ 
tion, practically all of the energy is derived from protein. If protein 
and carbohydrate alone or protein and fat alone be given to an animal, 
less protein is destroyed with a liberal supply of carbohydrate than a 
liberal supply of fat. Rubner succeeded in reducing the nitrogen output 
of a starving man one-half by giving carbohydrate. Carbohydrate is 
therefore called a sparer of protein, and it is evident that carbohydrate 
is a better sparer of protein than fat. But if both carbohydrate and fat 
be given, in addition to protein, they appear to be dynamically equivalent, 
calory for calory. Landergren found that a diet furnishing one-half of 
its calories as fat and one-half as carbohydrate protects protein as com¬ 
pletely as a diet composed entirely of carbohydrate. 

While carbohydrate cannot replace the protein required for the growth 
and repair of the cells of the body, it is probably necessary for the forma¬ 
tion of the perfect protein molecule. 

Uses of Fat.—Eat constitutes an important source of energy, and, 
like carbohydrate, is a sparer of protein. The fat of the food, when not 
needed immediately for oxidation, is deposited in the tissues of the body. 
The principal fat depots are the subcutaneous tissues, the liver, the perito- 


USES OF FOODS 


73 


neum, and the tissues about the kidneys. These depots constitute a reserve 
supply of fat, to he called upon in time of need. The duration of life 
under the condition of starvation generally depends upon the quantity of 
fat present in the organism at the start (Lusk). The sources of the body 
fat are the fat of the food, which may be deposited without change, and 
carbohydrate, which is readily transformed into fat. 

It has not been definitely proven whether fat can be formed in the 
human body from protein; however, the evidence tends strongly to sub¬ 
stantiate such a view. Fats may be formed from carbohydrates, but the. 
exact mechanism of the process is still somewhat obscure. It is likewise 
uncertain whether glycogen can be formed from fat. 

Uses of Water.—Approximately two-thirds of the body consists of 
water. Water forms an integral part of practically all the tissues, and 
serves as a means of transporting nutrients to, and waste products from, 
the cells. Since water is constantly given off from the body through the 
kidneys, skin, lungs, and in the feces, it is evident that, to maintain the 
composition of the tissues, these losses must be made good. Animals die 
sooner of thirst than of hunger. Deprivation of water causes not only a 
change in the composition of the tissues, but appears to lead to the devel¬ 
opment of toxic albuminous products. 

The average daily water requirement is about two liters, of which 
one-fourth is taken in the form of solid food. The demand for water in 
health varies directly with the losses, which in turn vary with the amount 
of exercise, the external temperature, and the character of the diet. A 
diet consisting largely of protein increases the desire for water. The 
variations in the demand for water which are occasioned by disease are 
seen in fevers, diabetes mellitus, and chronic interstitial nephritis. 

Deprivation of water increases the destruction of protein in the major¬ 
ity of instances, though to a less extent in fat than in spare persons. Pav¬ 
lov has called attention to the diminution of the gastric and pancreatic 
secretions which follows a deficient intake of water. Limiting the amount 
of water does not increase the destruction of fat, as was formerly believed. 
This fact has special significance in the treatment of obesity. 

Uses of Salts.—Organic life is dependent upon the presence of salts. 
Salts enter into the composition of living matter, and therefore are true 
foods. 

The elements concerned in mineral metabolism have a diversity of 
important functions in the body. The skeletal structure of the body, 
namelv, bone, owes its permanence and rigidity to its composition of the 
mineral salts; furthermore they are essential solid constituents of the 
soft tissues of the body, such as muscles, etc. By virtue of their being 
soluble salts, held in solution in the various fluids of the body, they exert 
their influence in blood-clotting, irritability of muscle and nerve, and 
the maintenance of the slight alkalescence of the body fluids, at the same 


74 


NUTRITION AND DIETETICS 


time furnishing acidity or alkalinity to the digestive juices. They also 
influence the solvent power and osmotic pressure of the blood and tissue 
fluids. 

A man under average conditions excretes from 20 to 30 grams of 
mineral salts per day. 


Tiie Vitamins 

Studies in nutrition in recent years have firmly established that the 
food factors known as vitamins are indispensable for the welfare of the 
animal organism. It is only within the last ten or fifteen years that we 
have realized that chemical analyses of foods for proteins, carbohydrates 
and minerals are insufficient to reveal their biologic value. Formerly 
a food was considered sufficient for nutritive requirements of the body 
if it fulfilled certain established standards as to total digestibility, avail¬ 
able energy and proteins. To-day, in addition to the above requirement, 
we recognize the need of certain essential substances—the vitamins. 

Hopkins was the first to demonstrate clearly that normal nutrition 
requires other food substances than proteins, carbohydrates, fats and min¬ 
erals. The name “vitamine” was given to these substances by Casimer 
Eunk in connection with his work on beriberi. McCollum and Kennedy 
suggested that we call them fat soluble (A), water soluble (B), to which 
was soon added water soluble (C). Drummond has simplified the ter¬ 
minology by proposing that we drop the final e and retain vitamin as a 
group name and use letters for distinguishing the various known members 
until chemical names are justified. Hence according to Drummond they 
shall be called vitamin (A), (B), (C), (D), etc. This later terminology 
has been quite generally accepted and will he used in the following 
discussion. 

Our knowledge of vitamins is still in the “making” and our present 
concept may he wholly changed in the coming years. At present we know 
of three vitamins with quite strong evidence of a fourth. The chemical 
constitution of all is still unsolved. 

Vitamin (A).—Hopkins, in 1906, found that young mice failed to 
grow upon a mixture of purified proteins, carbohydrates, fats and salts, 
while the addition of milk or the alcoholic extract of milk rendered such 
a diet adequate for normal nutrition and growth. McCollum and Davis, 
and Osborne and Mendel independently discovered that young rats grew 
or failed to grow depending whether the diet contained butter or lard. 
This gave evidence of some fat soluble substance in butter fat which pro¬ 
moted growth. Later Osborne and Mendel found that rats suffering 
from lack of vitamin (A) developed a peculiar eye disease called 
“xerophthalmia.” 

Effect of Lack of Vitamin (A).—Young animals at least cease to 


THE VITAMINS 


75 


grow and usually develop the eye disease. The occurrence of the eye 
disease has also been noted among children suffering from vitamin (A) 
deficiency. Block reports of the Danish children whose xerophthalmia 
yielded readily to diets rich in vitamin (A). McCollum, Simmonds and 
Parsons have attributed “night blindness,” an eye trouble in northern 
regions, to use of diets poor in vitamin (A). The lack of vitamin (A) 
may cause abnormalities and weaknesses other than the eye. Osborne 
and Mendel refer to diarrhea and diminished appetite, and McCollum and 
Davis and Drummond to lung weakness. 

Distribution of Vitamin (A).—It is quite widely distributed through¬ 
out nature, occurring in many of the animal fats, such as butter fat and 
cod-liver oil, but is generally lacking in all vegetable oils. It is present 
in most of the leafy foods and in many roots such as carrots and sweet 
potatoes. 

Physical and Chemical Properties of Vitamin (A).—It is usually 
associated with fats and is soluble in the ordinary fat solvents. It is 
quite readily destroyed by oxidation, such as aeration at high temperature 
or ozone. It is not very rapidly destroyed at temperatures below 100° C. 
and apparently withstands such treatment as cooking, canning and 
drying. 

Vitamin (B).—To Eijkman and Hopkins we must attribute the credit 
of calling attention to this unknown substance which Funk christened 
vitamin. Beriberi, a disease of the Orient, where polished rice and fish 
are the principal foods, has long been known. Eijkman in 1897 was able 
to produce a similar condition in pigeons and found that by adding the 
rice polishings to the diet the symptoms were relieved. The growth- 
promoting substances demonstrated by Hopkins in milk and called by 
McCollum water soluble (B) are probably identical with the antineuritic 
substance which Funk called vitamin; however, there is some difference 
of opinion as to whether vitamin (B) is an entity. 

Effect of Lack of Vitamin (B). —In diets lacking in vitamin (B) 
young animals cease to grow, become weak and usually polyneuritic. In 
man it may lead to beriberi. M^endel and Osborne and Karr have demon¬ 
strated the influence of vitamin (B) upon the appetite. 

Occurrence of Vitamin ( B ).—In plants it appears relatively abun¬ 
dantly in leaves, roots, tubers, seeds and fruits, and in animals in the 
glandular organs, eggs and milk. 

Physical and Chemical Properties of Vitamin (B).— It is readily 
soluble in water and dilute alcohol. It is more stable in acid than alkaline 
solutions. Chick and Hume have found that it is little destroyed by two 
hours’ heating at 100° C., about one-half destroyed in forty minutes at 
113° C. and up to nine-tenths destroyed in two hours at 118° to 124° C. 
From these results little destruction should occur in ordinary cooking, hut 
commercial canning and sterilizing may cause considerable loss. In cook- 


76 NUTRITION AND DIETETICS 

ing it may be very nearly all lost by extraction if the cooking water is 
rejected. 

Vitamin (C).— Scurvy has long been attributed to a faulty diet. Holst 
and Frohlich found that guinea pigs readily developed scurvylike symp¬ 
toms when fed on a cereal or bread diet. These workers found that the 
introduction of fresh carrots or cabbage would readily cure the diseased 
condition. They concluded that scurvy is caused by a lack of a chemical 
substance from the scorbutic diets, and further demonstrated that it was 
easily destroyed by cooking or drying. That scurvy is a deficiency of 
vitamin (C) has been affirmed by Hess, Cohen and Mendel and others. 

Effect of Lack of Vitamin (0).—The lack of vitamin (C) causes the 
development of scurvy both in young and adult. The disease is charac¬ 
terized by swollen and bleeding gums, loosening of the teeth, and charac¬ 
teristic lesions of the mucous membranes. 

Distribution of Vitamin (C). —Among the vegetable foods, fruits 
and succulent vegetables, such as oranges, lemons, tomatoes and fresh cab¬ 
bage, are the best sources. In the animal products it is present in milk 
and small quantities in meat. 

Physical and Chemical Properties of Vitamin ( C ).—It is readily 
water soluble, and more stable in acid than alkaline solutions. It is quite 
readily destroyed by heat, oxidation and drying. From studies made on 
its stability it is found that less of its potency is lost in heating at a high 
temperature for a short time than the reverse. This is important in the 
matter of dried milk. Hart, Steenbock and Smith have found that dried 
milk made by the drum process retains considerable antiscorbutic value, 
while that made by the spray process is of much less potency. 

Vitamin (D).—Recently strong evidence is being furnished that we 
have a fourth member of the interesting vitamin family, vitamin (D), 
which is intimately connected with the calcification of bone. Hess in his 
studies upon infantile rickets has demonstrated that cod-liver oil is almost 
a specific for rickets. McCollum, Simmonds, Shipley and Park present 
very substantial evidence of an antirachitic vitamin present in cod-liver 
oil, which is distinct from vitamin (A). So far this vitamin seems to be 
limited to the fish liver oils, such as cod-liver oil. 

Selection of Vitamin Diets.—There is no reason to suppose that the 
vitamin needs of the body cannot be supplied by use of our widespread 
natural foods. Many widely advertised products have appeared on the 
market, claiming special virtue in their vitamin content. Bailey at the 
Connecticut Agricultural Experiment Station has biologically analyzed 
a number of these commercial vitamin compounds, using as a standard 
dried brewer’s yeast. When analyzed on this basis, approximately 50 per 
cent of the advertised compounds showed inferior vitamin content. A 
few showed about an equal potency and only two or three of the products 
studied showed a greater potency than yeast. 


THE VITAMIN" CONTENT OF FOODS 


77 


In order to include vitamins in our diets, it becomes necessary to 
know how to choose such a diet. Certain approximations of the vitamin 
content of foods have been made, and may be used as a limited guide 
in selecting vitamin diets. The following table has been copied from 
The Vitamin Manual, and acknowledgment is hereby given . 1 


Vitamin Content op Foods * 


Classes of Foodstuffs 

Vitamin (A) 

Vitamin (B) 

Vitamin (C) 

Fats and oils 

Butter . 

+ + + 

o 


Cream . 

~b“b 

o 


Cod-liver oil . 

+ + + 

o 


Mutton and beef fat or suet.. 
Lard. 

++ 

0 



Olive oil. 

0 



Cottonseed oil . 

Coconut oil. 

0 

0 



Cocoa-butter. 

0 



Linseed oil. 

0 



Fish oil, whale oil, herring 
oil, etc. 

++ 



Hardened fats (hydro¬ 

genated) of animal or vege¬ 
table origin.. 

0 



Margarin from animal fat. .. 

Margarin from vegetable fat 
or lard .. 

In proportion 
to animal fat 
used 

0 



Nut butters. 

+ 



Meat, fish, etc. 

Lean meat (beef, mutton, 
p.t,r» ) . 

+ 

+ 

+ 

TiiyM* . 

++ 

+ + 

+ 

Kidneys. 

++ 

+ 


Heart. 

++ 

+ 


Brain . 

+ 

+ + 


Sweetbreads . 

+ 

H—b 


Fish white... 

0 

Very slight 


Fish fat (salmon, herring, 
) T . 

++ 

if any 

Very slight 
if any 

+ ~b 


Fish yee. 

+ 


Tinned meats.. 

2 

Very slight 

0 




*4. + + indicates abundant; + + relatively large; + present in small amount; 0 absent. 


Fddy, Walter H., The Vitamin Manual, published by Williams and Wilkins. 





































78 NUTRITION AND DIETETICS 


Vitamin Content of Foods* ( continued ) 


Classes of Foodstuffs 

Vitamin (A) 

Vitamin (B) 

Vitamin (C) 

Milk, cheese, etc. 

Milk, cow’s, whole, raw. 

+ + 

+ 

+ 

Milk, cow’s, skim . 

0 

+ 

+ 

Milk, cow’s, dried, whole. .. . 

Less than 


Less than 

Milk, cow’s, boiled, whole. ... 

H—h 

2 


+ 

Less than 

Milk, cow’s, condensed, sweet¬ 
ened . 

+ 

+ 

+ 

Cheese, whole milk. 

+ 


Less than 

Cheese, skim milk. 

Eggs, fresh. 

0 

++ 

+ + + 

+ 

0? 

Eggs, dried. 

++ 

+ + + 

0? 

Cereals, pulses, etc. 

Wheat, maize, rice (whole 
germ) . 

+ 

+ 

0 

Wheat, maize, rice germ. 

+ + 

+ + + 

0 

Wheat, maize, rice bran. 

0 

-I- + 

0 

White wheat flour, pure corn 
flour, polished rice, etc. 

0 

0 

0 

Custard powders, egg substi¬ 
tutes, prepared from cereal 
products. 

0 

0 

0 

Linseed, millet. 

++ 

++ 

0 

Dried peas, lentils, etc. 

Pea-flour, kilned. 


++ 

0 

0 

Soy beans, haricot beans. 

+ 

++ 

0 

Germinated pulses or cereals. 

+ 

++ 

++ 

Vegetables and fruits 

Cabbage, fresh; raw. t 

++ 

+ 

+++ 

Cabbage, fresh, cooked. 


+ 

+ 

Cabbage, dried. 

+ 

+ 

Very slight 

Cabbage, canned. 

Swedes, raw, expressed juice. 
Lettuce. 

++ 

+ 

Very slight 
+ + + 

Spinach, dried. 

++ 

+ 


Carrots, fresh, raw. 

+ 

+ 

+ 

Carrots, dried . 

Very slight 


Less than 

Beetroot, raw, expressed juice. 

+ 

+ 

+ 

Potatoes, raw. 

Potatoes, cooked . 

Beans, fresh scarlet runners 

raw. 

Lemon juice, fresh. 

Lemon juice, preserved. 



+ 

+ + 

+++ 


* + + + indicates abundant; ++ relatively large; + present in small amount; 0 absent. 











































THE VITAMIN CONTENT OF FOODS 79 


Vitamin Content of Foods* ( continued ) 


Classes of Foodstuffs 

Vitamin (A) 

Vitamin (B) 

Vitamin (C) 

Vegetables and fruits—Cont. 




Lime juice, fresh. 



-)—[- 

Lime juice, preserved. 



Very slight 

Orange juice, fresh. 



+++ 

Raspberries. 



4-4- 

Apples . 



T r 

“f" 

Bananas. 

+ 

+ 

Very slight 

Tomatoes, canned. 



+ + 

Nuts. 

+ 

+ + 


Miscellaneous 



Yeast, dried . 

? 

+ + + 


Yeast extract and autolyzed. 

? 

+ + + 

0 

Meat extract. 

0 

0 

0 

Malt extract. 


+ in some 




specimens 


Beer . 


0 

0 

Honey . 


+ 


Meats 




Beef heart. 

+ 

+ 

? 

Brains . 

++ 

+ + + 

+ ? 

Codfish. 

+ 

+ 

? 

Codtestes. 

+ 



Fish roe. 

+ 

+ + 

? 

Herring. 

++ 

+ + 

? 

Horse meat. 

• + 

+ 


Kidney. 

4+ 

+ + 


Lean muscle. 

0 

0 

+ ? 

Liver . 

4 

+ 

+ ? 

Pancreas . 

0 

+++ 


Pig heart. 

4 

+ 

? 

Placenta . 


+ 


Thymus, sweetbreads . 

0 

0 

0 

Vegetables 




Beet root. 

4 

+ 

+ 

Beet root juice. 

? 

Little 

+++ 

Cabbage, dried. 

444 

+ + + 

+ 

Cabbage, fresh. 

444 

+ + + 

+ 4 f + 

Carrots. 

444 

+ + + 

+ + 

Cauliflower. 

44 

+ + + 

+ + 

Celery . 

? 

+++ 

? 

Chard. 

444 

+ + 

2 

Dasheens. 

+ 

++ 

? 

Lettuce. 

44 

+ + 

+ + + + 

Mangels. 

44 

++ 

? 

Onions. 

? 

+ + + 

+++ 

Parsnips . 

44 

+ + + 


Peas, fresh . 

+ 

++ 

+ + + 


* + + + indicates abundant; ++ relatively large; + present in small amount; 0 absent. 




























































80 


NUTRITION AND DIETETICS 

Vitamin Content of Foods* ( continued ) 


Foodstuffs 

Vitamin (A) 

Vitamin (B) 

Vitamin (C) 

V egetables—Cont. 

Potatoes .. 

0 

+ + + 

+ + 

Pot a tops SWPPt,. 

+++ 

TT 

? 

Pntnhngn. 

+ + + 


Spinach . 

+ + + 

+++ 

+ + + 

Cereals 

Barley . 

+ 

+ + + 

? 

Bread white. 

+ ? 

Bread, whole meal. 

T 

+ + + 

? 

Maize. 

f + In yellow \ 
1 0 In white i 
+ 

+ + + 

? 

Oats . 

+++ 

0 

Bice, pnli sli pel. 

0 

0 

0 

B.iee, whole grain . 

+ 

+++ 

0 

Bye.. 

+ 

+++ 

0 

Corn embryo ... . i. 

Corn TCaffir . 

+++ 

+++ 


Corn Mai/el . 



Corn pollpn. 


++ 


Malt extract. 

0 

0 

0 

Wheat bran. 

0 

+ 

0 

Wheat embryo. 

++ 

+++ 

0 

Wheat endosperm. 

0 

0 

0 

Wheat kernel. 

+ 

+++ 

0 

Other seeds 

Beans, kidney. 


+++ 


Beans, navy . 


+++ 

0 

Beans, soy. 

+ 

+++ 

0 

Cotton seed. 

++ 

+ T + 


Flaxseed . 

++ 

+++ 


Hemp seed. 

++ 

+++ 


Millet seed . 

++ 

++-F 


Peanuts.. 

Peas, dry. 

+ 

+ ? 

++ 

++ 

o 

Sunflower seeds. 

+ 


Fruits 

Apples . 

++ 

++ 

++ 

+++ 

+ 

Bananas . 

? 

+ 

Grapefruit. 

+ + + 

Grape juice. 


+ 

Grapes . 

o 

+ 

+ 

++++ 
d—b 

Lemons . 


+ + + 

Limes .. ... 


++ 

+ + + 

Oranges. 


Pears . 


+ + 

++ 

4- 

Baisins. 


+ 

Tomatoes .. 

++ 

+ + + 

+ + + + 



* + P + indicates abundant; -f + relatively large; -f present in small amount; 0 absent. 























































THE VITAMIN CONTENT OF FOODS 

Vitamin Content of Foods* ( continued ) 


81 


Foodstuffs 

Yitamin (A) 

Yitamin (B) 

Vitamin (C) 

Oils and fats 




Almond oil. 

0 

0 


Beef fat. 

+ 

0 

0 

Butter . 

++++ 

0 

0 

Coeonnt, oil. 

0 

0 

0 

Cod-liver oil. 

++++ 

0 

0 

Corn oil . 

0 

0 

0 

Cotton-seed oil. 

0 ? 

0 

0 

Fp-o'-yolk fat,. 

++++ 

0 

0 

Fish oils. 

++ 

0 

0 

Lard . 

0 ? 

0 

0 . 

Oleo, animal. 

+ 

0 

0 

Oleo, vegetable. 

0 

0 

0 

Olive oil . 

0 

0 

0 

Pork fat, . 

0 ? 

0 


Tallow . 

0 

0 

0 

■yVorptable oils . 

0 ? 

0 

0 




Nuts 




Almond . 

+ 

+++ 




+++ 


Chestnut . 


+++ 


Cnnomit. . 

+ 4- 

++'+ 


Fnedish walnut . 

+++ 


F ilbert. 


+++ 


TTiVkotv .. 

+ 

+ 

+ 

Ping . 

+ 

+ 

+ 

Dairy products 

++++ 



Bnt.ter . 

0 

0 

Cheese . 

++ 

+ 

? 

(Trmrlpnfipcl milk . 

++ 

+ 

0 

Cream . 

+++ 

+ 

? 

Forcra . 

++++ 

++ 

0 

llfillr DOWflpT ftkim . 

+ 

+++ 

+ ? 

Ivlllri puwucij .. 

IVTillr nnwrlpr wViolp . 

+++ 

+++ 

+ ? 

"Milk whole . . . 

+++ 

+++ 

++ 

Whev ....» 

+ 

+++ 

+ 

Miscellaneous 


+++ 

? 

A lfnl fa . 

+++ 

Blood . 


Varies with 




source 


Clover . 

+++ 

H — b + 4* 

? 

IT rm pv „... 


+ + 

0 


0 

A 

A 

IVlal'f . . . . . . . 

U 

1/ 


0 

0 

0 

Timot.hv . 

++ 

++ + 


"Vencit brewer’s . 

0 

++ + + 

0 

Y nnof PQ1TPQ . . . ... 

0 

H—h 

0 

Yeast extract. 

0 

++ + 

0 


. + + + indicates abundant; ++ relatively large; + present In small amount; 0 absent. 






















































82 


NUTRITION AND DIETETICS 


Condiments —Under the general term, Accessory articles of diet,” are 
classed the condiments, flavors, and stimulants. These substances are 
added to our diets to increase their attractiveness and palatability, al¬ 
though they may impart a certain amount of energy by their oxidation. 
Some of these substances, due to their increasing palatability, exert a 
so-called psychical stimulation which facilitates gastric secretion and thus 
materially aids in gastric digestion. 

Gauthier has divided condiments into the following classes: (1) aro¬ 
matics, comprising vanilla, anise, cinnamon, nutmeg, and other essential 
oils; (2) peppers; (3) the alliaceous condiments—garlic, mustard, etc.; 
(4) acid condiments—vinegar, citron, pickles, etc.; (5) the salty condi¬ 
ments, such as table salt; (6) the sugar condiment. Under the head 
of stimulants are included alcohol, tea, coffee, cocoa, chocolate, and meat 
extracts. 

Alcohol .—The exact value of alcohol as a food is somewhat uncertain. 
Experiments made on man, however, clearly show that alcohol is burned 
up in the body. Its potential energy is transformed into kinetic energy, 
and therefore alcohol is considered as having food value. While it acts 
as a food sparer, it may not he a desirable food. Prior to its oxidation 
in the body, alcohol may produce deleterious effects of various kinds, 
which counterbalance the gain from its oxidation. 

Tea and Coffee .—The stimulating effect of tea and coffee is due to 
the presence of caffein. This alkaloid has a diuretic action on the kidney 
and raises blood-pressure. Muscular energy is augmented and the sense 
of fatigue is dissipated by the use of these stimulants. 

Cocoa .—Chocolate made from cocoa by the addition of sugar and 
flavoring agents acts as a stimulant through its content of theohromin. 
It also contains fats, carbohydrates and protein. 

Meat Extracts .—In themselves these extracts have very little food 
value. Their value lies in their content of nitrogenous extractives, many 
of which are stimulants. They also call forth a copious secretion of 
gastric juice and for this reason have been called secretogogues. 

Acid-forming and Base-forming Foods 

The reaction of normal human blood is slightly alkaline, hut this is 
so slight that blood and protoplasm may he spoken of as neutral. 

The processes of metabolism cause a continual production of acid 
(carbonic, phosphoric, and sulphuric) which must he disposed of in order 
to maintain neutrality. 

The factors that are concerned in the maintenance of neutrality are 
(1) carbonates, (2) phosphates, (3) ammonia, (4) proteins. 

Henderson has worked out the various relationships of the different 
factors in the maintenance of neutrality under normal conditions. The 


ACID-FORMING AND BASE-FORMING FOODS 83 

hydrogen ion concentration depends upon the ratio of H 2 C0 3 . The 

NaHCOa 

mechanism of the maintenance of this ratio is too involved for detailed 
discussion here, and the reader is referred to other sources. 2 

The normal acid production in man on mixed diets is taken care of, 
in part at least, by the formation and excretion of acid phosphates. An 
increased acidity of the urine usually means an increased ratio of pri m ary 
phosphates to secondary phosphates, but without any necessary increase 
of fixed alkali leaving the body. In the neutralization of sulphuric acid 
by phosphates, each molecule of sulphuric acid converts two molecules of 
secondary into primary phosphate. This surplus of acid phosphate must 
be excreted to maintain the normal equilibrium. The neutralization of 
sulphuric acid, formed in the metabolism of proteins by potassium or 
sodium carbonate of the blood, may lead to a depletion of fixed alkali 
in the blood. 

Formerly it was believed that ammonia was used for neutralization 
of acid by the liver and tissues. Recently, however, Nash and Benedict 
have demonstrated that ammonia does not exist in the blood, except in 
traces, and that the kidney is the seat of ammonia formation. Under 
these circumstances acids must be transported in the body in combina¬ 
tion with fixed bases or proteins. Thus there may occur a loss of fixed 
alkali from the body when there is a more rapid introduction of acid 
radicals into the blood-stream than the normal kidney can eliminate or 
can make ammonia to combine with them while eliminating. Thus when 
there is an abundance of strong acid to be neutralized, unless made good 
by the base-forming elements of the food, there probably results loss of 
fixed alkali with a lowering of the “alkali reserve” of the blood. Hence, 
there is a relationship among the ash constituents of the food in acid¬ 
forming and base-forming elements, in the maintenance of neutrality of 
the body. 

While a continuous excess of acid-forming elements in the diet is 
probably not harmful, the decreased uric acid solvent power of acid urines 
is well known. 

Blatherwick has studied a considerable number of the foods, and found 
that foods with a preponderance of base-forming elements tended to de¬ 
crease the acidity of the urine, and to increase its solvent power for uric 
acid, while a preponderance of acid-forming elements tended to form a 
more acid urine with a decreased uric acid solvent power, and a tendency 
toward a depletion of the alkali reserve. 

The following foods have been studied by Sherman and Gettler: 3 

2 Van Slyke and Coworkers. Journal of Biological Chemistry, 1917, xxx, 289, 347, 
401; 1917, xxxii, 455, 495; 1918, xxxiii, 271; 1919, xxxviii, 167; 1920, xli, 567; 1921, 
xlviii, 153. 

3 Sherman and Gettler. Journal of Biological Chemistry, 1912, xi, 523. 





84 


NUTRITION AND DIETETICS 


Ash Analyses of Sherman and Gettler: Excess of Acid-forming or 
Base-forming Elements 

(Excess Acid or Base in Terms of Normal Solutions) 


Articles of Food 

Per 100 

Grams 

Per 100 

Calories 

Acid 

c.c. 

Base 

c.c. 

Acid 

c.c. 

Base 

c.c. 

Almonds . 

.... 

12.38 

.... 

1.86 

Apples . 


3.76 

.... 

5.98 

Asparagus . 


0.81 

.... 

3.65 

Bananas . 


5.56 

.... 

5.62 

Beans, dried . 


23.87 

.... 

6.92 

Beans, lima, dried. . . 


41.65 


12.08 

Beets . 


10.86 


23.57 

Cabbage . . 


4.34 


13.76 

Carrots. 


10.82 

.... 

23.91 

Cauliflower ... 


5.33 

.... 

17.48 

Celery . 


7.78 


42.17 

Cherry juice. 

.... 

4.40 

.... 

.... 

Chestnuts. 


7.42 


3.19 

Corn, sweet, dried. .. 

5.95 


1.77 

• • • • 

Crackers . 

7.81 

• • • • 

1.95 

• • • • 

Currants, dried . 

.... 

5.97 

• • • • 

1.85 

Eel . 

9.89 

.... 

• • • • 

• • • • 

Eggs . 

11.10 


7.55 

• • • • 

Egg white . 

5.24 

.... 

9.52 

• • • • 

Egg yolk . 

26.69 

.... 

7.08 

• • • • 

Fish, haddock. 

16.07 

.... 



Fish, pike. 

11.81 

.... 

• • • • 


Lemons. 

.... 

5.45 

.... 

12.32 

Lettuce . 

.... 

7.37 

.... 

38.69 

Meat, beef, lean . 

13.91 

, , , , 

12.10 

.... 

Meat, chicken . 

17.01 




Meat, frog . 

10.36 

• • • • 



Meat, pork, lean . 

11.87 

• • • • 



Meat, rabbit . 

14.80 

• • • • 



Meat, veal . 

13.52 

• • • • 



Meat, venison . 

15.83 

• • • • 



Milk, cow’s . 


2.37 

.... 

3.44 

Muskmelon . 


7.47 


18.82 

Oatmeal . 

12.93 


3.23 


Oranges .. 

.... 

5.61 


10.94 

Peaches . 


5.04 


12.20 

Peanuts. 

3.9 


0.70 


Peas, dried . 


7.07 


1.98 

Potatoes. 

.... 

7.19 


8.63 

Prunes . 


24.40 


8.05 

Radishes. 


2.87 


9.79 

Raisins . 

.... 

23.68 


6.87 

Raspberry juice .... 

.... 

4.91 


Rice . 

8.1 


3.35 


Turnips . 


2.68 


6.86 

Wheat, entire. 

9.66 

.... 

3.25 


Wheat, flour. 

11.61 

.... 

2.70 

.... 




































































TOTAL FOOD REQUIREMENT 


85 


Total Food Requirement 


The body derives the energy required for the performance of its func¬ 
tions from the food, the potential energy of the food being transformed 
into heat and work. Without some knowledge of the food requirements in 
health, it will he found difficult to arrange rational dietaries for patients. 
In health the appetite constitutes the chief guide to our needs and is in 
the main reliable. That it is not always so is evidenced by the various 
disorders from overindulgence or underindulgence in food. 

Two methods have been employed to determine the daily food require¬ 
ment of man, the empiric and the experimental. The empiric method 
consists in studying the food-habits of a large number of people in various 
occupations and taking the average quantities of food, and foodstuffs, con¬ 
sumed by each class. The experimental method consists essentially in 
measuring, in terms of heat, the amount of energy produced by the body 
under different conditions, as when at work, at rest, and on different diets. 
Many important facts have been obtained from studies of metabolism 
carried out upon the lower animals. 

Our present knowledge concerning metabolism in man has been de¬ 
rived from both the empiric and experimental methods. The results of 
these studies have furnished us with what are known as standard require¬ 
ments. It should be pointed out, however, that these standards are not 
absolute; they are simply guides, which may, and should, be varied accord¬ 
ing to the requirements of different individuals. 

The total food requirement is generally expressed in calories or heat 
units. The term calory, unless qualified, may mean either the amount of 
heat necessary to raise 1 gram of water from 0° to 1° C., or 1,000 grams 
of water from 0° to 1° C. They are designated respectively as small and 
large calories. Usually the distinction is made by using an initial capital 
for the large calory, thus “Calory” means large calory. The term 
“calory,” as ordinarily employed in medical literature, should be inter¬ 
preted as large calory. 

The body follows the general law of the conservation of energy, that 
is, the energy yielded by the food which is actually absorbed and oxidized, 
and which is manifested as heat or heat and mechanical work, corresponds 
with the potential energy of the different foodstuffs consumed. There¬ 
fore, it is possible to calculate the fuel value to the body of the 
different foodstuffs. Rubner’s figures shown below are generally employed 
for the purpose. 


1 gram of protein furnishes. 

1 gram of fat furnishes.. 

1 gram of carbohydrate furnishes 
1 gram of alcohol furnishes. 


4.1 calories. 

9.3 

4.1 

7.0 “ 






86 


NUTRITION AND DIETETICS 


The total energy requirement may be expressed as calories per kilo¬ 
gram per day or calories per square meter of body surface per hour. The 
latter method is the more accurate, and the chart recently published by 
Du Bois and Du Bois makes the method practicable for bedside work (see 
Chart). 

The total energy requirement of an adult at absolute rest (that is, 
without voluntary movement of any kind) and twelve hours or so after 
food is 22 to 26 calories per kilogram per day, or 1,540 to 1,820 calories 
for a man weighing 70 kilograms (154 lbs.). The total energy require- 



Fig. 1.—Chart for Determining Surface Area of Man in Square Meters from 
Weight in Kilograms and Height in Centimeters. The point of intersection of 
ordinate and abscissa for any individual is found and the surface area read off on 
the curved lines. For example, if a man is 150 centimeters in height, and weighs 
60 kilograms, his approximate surface area will be 1.55 square meters. (After 
Du Bois and Du Bois.) 


ment by surface area is 39.7 calories per square meter per hour. Patients 
confined to bed are never at absolute rest, however, within the meaning 
of the term, except during sleep or when comatose, and the energy value 
of their food, except under special conditions and for brief periods, should 
not be permitted to fall below this minimum. 

A number of circumstances may modify the demand for energy. 
Among the more important of these are the age, size of the individual, 
amount of muscular work, and disturbances of metabolism brought about 
by various diseases. 

Age.—The rate of metabolism varies with the age of the individual. 
It is greatest in infancy and childhood and lowest in old age. As will 






























87 


TOTAL FOOD REQUIREMENT 

be seen on the chart (Chart 2), metabolism, which is low at birth, rises 
rapidly during the first year and reaches its maximum somewhere between 
the first and sixth years (this period has not been thoroughly investi¬ 
gated). After the sixth year it falls rapidly until the age of twenty, and 
thereafter very slowly. There is no difference between the sexes in 
infancy. After the sixth year girls and women have a distinctly lower 
metabolism. Du Bois found the heat production of boys, 12 to 13 years 
old, to be 25 per cent above the adult level. A surplus over the actual 
demand of the child should always be given to allow for growth. 

Heubner states that the energy requirement of a child in the first 
three months of life is 100 Calories per kilogram of body weight per day; 

60 


50 


40 


30 


20 


10 

Years 2 4 6 8 10 12 14 is is .20 22 

Fig. 2. — Chart Showing Variation of Basal Metabolism with Age. Calories per 
hour per square meter of body surface, Mech’s formula. Dash line shows average 
for males; dotted line for females. (After Du Bois.) 

in the second three months, 90 Calories ; thereafter, 80 Calories and less 
per kilogram. * The energy supply should not be allowed to fall below 70 
Calories per kilogram. 

Size. —In general, persons of large frame and build require more food 
than those who are small. The increase, however, corresponds to unit of 
surface area rather than to weight. For this reason, persons who are fat 
require relatively less food than those who are thin, though a fat person 
expends more energy in the performance of muscular work, because of 
the greater effort required to move his body. 

Muscular Work. —The performance of muscular work is accompanied 
by an increase in metabolism and a greater supply of food is demanded. 
The increase is chiefly at the expense of fat and carbohydrate, though 
when they are not available protein may be consumed. Many investiga- 


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88 


NUTRITION AND DIETETICS 


tions have shown the relation of muscular work to metabolism. The re¬ 
sults can be best illustrated by the following table, arranged by Atwater: 

Food Consumption of Persons in Different Circumstances, and Proposed 
Dietary Standards * 

(Quantities per man per day ) 



Actually Eaten 


Digestible 


Occupations 

Grams 

Pro¬ 

tein 

Grams 

Fat 

Grams 

Carbo¬ 

hy¬ 

drates 

Grams 

Pro¬ 

tein 

Grams 

Fat 

Grams 

Carbo- 

hy¬ 

drates 

Fuel 

Value 

in 

Calories 

Persons with Active Work 
Rowing clubs in New England 

155 

177 

440 

143 

168 

427 

3,955 

Bicyclists in New York. 

186 

186 

651 

171 

177 

631 

5,005 

Football teams in Connecticut 
and California. 

226 

354 

634 

208 

336 

615 

6,590 

Prussian machinists . 

139 

113 

677 

128 

107 

657 

4,270 

Swedish mechanics. 

189 

110 

714 

174 

104 

693 

4,590 

Persons with Ordinary Work 
Farmers’ families in eastern 
United States. 

97 

130 

467 

89 

124 

453 

3,415 

Mechanics’ families in United 
States .. 

103 

150 

402 

95 

143 

390 

3,355 

Laborers’ families in large 
cities of United States. 

101 

116 

344 

93 

no 

334 

2,810 

Laborers’ families in United 
States (more comfortable 
circumstances) . 

120 

147 

534 

119 

140 

518 

3,925 

Russian peasants . 

129 

33 

589 

119 

31 

571 

3,165 

Swedish mechanics. 

134 

79 

523 

123 

75 

507 

3,330 

Professional Men 

Lawyers, teachers, etc., in 
United States . 

104 

125 

423 

96 

119 

410 

3,220 

College clubs in United States 

107 

148 

459 

98 

141 

445 

3,580 

German physicians . 

131 

95 

327 

121 

90 

317 

2,680 

Japanese professor. 

123 

21 

416 

113 

19 

403 

2,345 

Men with Little or No Exercise 
Men (American) in respira¬ 
tion calorimeter . 

112 

80 

305 

103 

76 

296 

2,380 

Men (German) in respiration 
apparatus . 

127 

80 

302 

117 

76 

293 

2,430 

Persons in Destitute Circum¬ 
stances 

Poor families in New York 
City .. .. 

93 

95 

407 

86 

90 

395 

2,845 

Laborers’ families in Pitts¬ 
burg, Pa. 

80 

95 

308 

74 

90 

299 

2,400 

German laborer’s family. 

52 

32 

287 

48 

30 

278 

1,640 

Italian mechanics. 

76 

38 

396 

70 

36 

384 

2,225 


* Fats and carbohydrates in sufficient amounts to furnish, together with the protein, 
the indicated amount of energy. 








































VARYING FOOD REQUIREMENT 


89 


Food Consumption of Persons in Different Circumstances, and Proposed 
Dietary Standards ( Continued ) 



Actually Eaten 

Digestible 

Fuel 

Value 

in 

Calories 

Occupations 

Grams 

Pro¬ 

tein 

Grams 

Fat 

Grams 

Carbo¬ 

hy¬ 

drates 

Grams 

Pro¬ 

tein 

Grams 

Fat 

Grams 

Carbo- 

hy¬ 

drates 

Miscellaneous 

Negro families in Alabama and 
Virginia . 

86 

145 

440 

79 

138 

427 

3,395 

Italian families in Chicago. .. 

103 

111 

391 

95 

105 

379 

2,965 

French Canadians in Chicago. 

118 

158 

345 

109 

150 

335 

3,260 

Bohemian families in Chicago 

115 

101 

360 

106 

96 

349 

2,800 

Inhabitants Java village, Co¬ 
lumbian Exposition, 1893. .. 

66 

19 

254 

61 

18 

246 

1,450 

Russian Jews in Chicago. 

137 

103 

418 

126 

98 

405 

3,135 

Mexican families in New 
Mexico. 

94 

71 

613 

86 

67 

595 

3,460 

Chinese dentist in California. 

115 

113 

289 

106 

107 

280 

2,620 

Chinese laundryman in Cali- 
fomia. 

135 

76 

566 

124 

72 

549 

3,480 

Chinese farm laborer in Cali- 
fornia. 

144 

95 

640 

132 

90 

621 

3,980 

United States Army ration, 

peace . 

German army ration, peace. .. 

120 

161 

454 

110 

153 

440 

3,730 

114 

39 

480 

105 

37 

466 

2,725 

Dietary Standards 

Man at hard work (Voit) 

145 

100 

450 

133 

95 

437 

3,270 

Man at moderate work (Voit) . 

118 

56 

500 

109 

53 

485 

2,965 

Man with very hard muscular 
work (Atwater) . 

175 

(a) 

(a) 

161 

(a) 

(a) 

5,500 

Man with hard muscular work 
(Atwater) . 

150 

(a) 

(a) 

138 

(a) 

(a) 

4,150 

Man with moderately active 
muscular work (Atwater) .. 

125 

(a) 

(a) 

115 

(a) 

( a) 

3,400 

Man with light to moderate 
muscular work (Atwater) .. 

112 

(a) 

(a) 

103 

(a) 

(a) 

3,050 

Man at “sedentary” or woman 
with moderately active work 
(Atwater) . 

100 

(a) 

(a) 

92 

(a) 

(a) 

2,700 

Woman at light to moderate 
muscular work, or man with¬ 
out muscular exercise (At- 
water) . 

90 

(a) 

(a) 

83 

(a) 

( a ) 

2,450 


The energy requirement of adults, reduced to calories per kilogram of 
body weight, may be summarized in the following table (von Noorden). 
In general, a man at nearly complete rest requires on the average one 
calorie per kilogram per hour. 





































90 


NUTRITION AND DIETETICS 


Calories Per Kilogram Per Day 


Absolute rest . 24-30 

Ordinary rest in bed. 30-34 

Out of bed without work. 34-40 

Moderate work. 40-45 

Hard work. 45-60 


Protein, Eat, and Carbohydrate Ratios 

The relative proportions of protein, fat, and carbohydrate which 
should enter into the diet must be considered, as well as the total food 
requirement. 

Protein Requirement.—The daily protein requirement is an important 
question in nutrition, and has been the subject of much discussion. The 
optimum protein ration has not yet been determined. It probably varies 
with different individuals and under different conditions, such as external 
temperature, amount of work done, etc. 

It has been assumed that a healthy man under normal conditions would 
consume daily the amount of protein which he has found by experience 
to be suited to his needs. The almost universal support which has been 
accorded to Voit’s recommendation, until recently, is essentially a recog¬ 
nition of this assumption. After studying the food-habits of a large num¬ 
ber of people, Voit placed the daily protein requirement of a man at light 
work at 118 grams. Atwater, employing the same method, found the re¬ 
quirement to be 125 grams a day. But within the last fifteen years or so 
the correctness of the Voit and Atwater standards has been called into 
question, largely on the basis of experimental as contrasted with statistical 
studies. Probably the most important of these investigations has been car¬ 
ried out by Chittenden. 4 He believes “that the Voit and Atwater standards 
call for amounts of protein food far beyond the requirements of the 
body . . . provided the total calorific value of the food is sufficient 
. . . that the need for protein food may be fully met by a daily metabolism 
equal to an exchange of 0.12 grams of it per kilogram of body weight.” 
Eor a man of 70 kilograms (154 pounds), this represents 60 grams 
of protein a day, which is about one-half the Voit and less than half the 
Atwater standards. Chittenden’s investigations were carried out on pro¬ 
fessional men, students, and soldiers. The case of Professor Chittenden 
himself, suffering as he had for years from “rheumatism,” “bilious at¬ 
tacks,” and sick headaches, falls rather into the category of disease with 
possible disorders of digestion or metabolism, so that an excess of protein 
over his minimal needs acted injuriously. 


4 It will be assumed in the discussion of the daily protein requirement that fat 
and carbohydrate are supplied in sufficient amounts. 








FOOD RATIOS 


91 


More recently Chittenden has employed the statistical method on 
108 healthy persons selected at random, and he states that as a group 
they represented the average type of vigorous manhood common to most 
university centers. They metabolized on an average 0.19 gram of nitro¬ 
gen per kilogram of body weight, as contrasted with the 0.22 gram of the 
Yoit standard. There is, therefore, close correspondence between Chit¬ 
tenden’s experimental and statistical results. The statistical observations 
especially raise the question whether there may not be many persons whose 
daily protein requirement is entirely satisfied by appreciably less protein 
food than is called for by the Voit and Atwater standards. 

Chittenden’s views have met with vigorous opposition. It has been 
pointed out that the most progressive races of mankind consume protein 
in quantities approximating the Yoit and Atwater standards. Benedict 
cites the poor whites and negroes of the South as examples of the deleteri¬ 
ous effect of the low protein diet. ETiceforo calls attention to the sociologi¬ 
cal status of the laborers of southern Italy, and thinks it due to the small 
amount of protein in their diet. McCay has shown that the Bengalis, 
who are inferior in physical development to the Anglo-Indians and 
Eurasians, metabolize only about 37 grams of protein a day, or 0.11 gram 
nitrogen per kilogram of body weight. But it cannot yet be assumed that 
the relation of cause and effect in these cases has been established. 

Experiments upon the lower animals indicate that the injurious effects 
of a low protein diet may not manifest themselves for a year or more, 
and while it does not necessarily follow that similar injurious effects may 
be caused in man, yet the experiments suggest the need for caution in 
accepting Chittenden’s conclusions. According to Lusk, there appears to 
be no strongly substantiated argument why that portion of mankind living 
in a cool climate should not follow the general custom of taking a medium 
amount of protein in moderate accordance with the dictates of their 
appetites. 

Only a limited number of investigations into the protein requirement 
in disease have been made, and an attempt to state the requirement for 
different diseases would not be justified. Therefore, until the daily pro¬ 
tein requirement both in health and disease is more definitely determined, 
the wisest course for physicians and others, who have control of dietaries, 
appears to be to follow the older standards, or at least to permit persons 
to gratify their desire for protein food. 

Variations in the Protein Requirement .—The demand for protein 
varies within much narrower limits than the demands for fat and carbo¬ 
hydrate. An excess of protein is needed during the period of growth, and, 
according to Lusk, during “training,” to provide for the accompanying 
hypertrophy of the muscles. 

The demand appears to vary also with different persons of the same 
sociological status. It is a matter of common observation that some per- 


92 


NUTRITION AND DIETETICS 


sons eat more meat than others, and claim that their efficiency is impaired 
if their .usual supply is diminished. Old people, as a rule, take less 
protein than those in active middle life. 

Though protein is not concerned directly in the production of energy 
for muscular work, provided the fat-carbohydrate supply is sufficient, a 
greater amount of protein is allowed by both the Voit and Atwater stand¬ 
ards for occupations entailing physical exertion. No entirely satisfactory 
explanation of the increased demand has been offered. Voit assumed that 
muscles engaged in active work must have a free supply of protein quickly 
available. Magnus-Levy thinks that the increased consumption of pro¬ 
tein is not the result of purposeful selection, but is incidental to the in¬ 
crease in the total food. 

The inclination to diminish the amount of protein in hot weather and 
hot climates is general and finds its explanation in the high specific dy¬ 
namic action of protein, that is, the high proportion of potential energy 
which is liberated as free heat and which does not take part in the vital 
activities of the cells. 

Our knowledge of the protein requirement in pathological states is 
very incomplete. Large amounts of protein are often taken in diabetes 
mellitus and exophthalmic goiter. The belief is current that an excess of 
protein is required during convalescence from the acute infective diseases 
because of the febrile destruction of protein which occurs, but there is 
reason to question whether an excess is required, if, during the course 
of these diseases, adequate supplies of carbohydrate and fat are furnished. 

Injurious Effects of an Excess of Protein .—The body does not possess, 
to any marked degree, the power of storing nitrogenous substances. The 
carbonaceous moiety of the protein molecule is split off and the excess of 
nitrogen is quickly eliminated, chiefly as urea. It has been stated that 
the increased work thus demanded of the kidneys would damage them, but 
proof of the statement is lacking. An excess of protein in the diet fre¬ 
quently causes disturbances of digestion, which may or may not be 
referred subjectively to the alimentary tract. It appears probable that 
products of protein putrefaction may be absorbed and irritate the kidneys 
in their elimination, producing albuminuria, and perhaps ultimately caus¬ 
ing nephritis. Some headaches appear to be caused by disorders of pro¬ 
tein digestion or metabolism or both—at least, persistent headaches which 
are not due to any other discoverable cause sometimes disappear when 
the protein ration is reduced to a minimum and the form of the pro¬ 
tein is changed, for example, from meat to milk. Professor Chittenden 
found that his rheumatism grew better under the influence of a low pro¬ 
tein diet. Some forms of eczema disappear when meat is eliminated from 
the diet, and the total protein of the food is reduced (Johnston). It has 
not yet been proved whether an excess of protein is capable of causing 
arterial sclerosis. 


FOOD RATIOS 


93 


The Carbohydrate-Fat Requirement.—The greater portion of the 
energy of the body is derived from carbohydrate and fat. Since they are 
to a large extent interchangeable in the diet, they may be considered to¬ 
gether. While it is possible for men to live, and to thrive, upon a diet 
of protein and fat alone, as in the case of the Eskimos, or of protein and 
carbohydrate alone, physiologic economy makes it expedient that the 
diet should contain both fat and carbohydrate. In a mixed diet, carbo¬ 
hydrate and fat possess about equal power as protein sparers. As already 
stated, Landergren has shown that a diet furnishing half of its calories 
as fat and half as carbohydrate has the same power as a protein sparer 
as a diet of carbohydrate alone. As a source of energy, therefore, in a 
mixed diet, carbohydrate and fat are interchangeable in isodynamic 
amounts. 

The relative proportions of fat and carbohydrate in the average diet 
are given in the Voit and Rubner 5 standards. But the proportions vary 
according to personal taste and the ability of the individual to digest fat. 
Large amounts of fat in a mixed diet are difficult to digest, due, as Pav¬ 
lov has shown, to the inhibiting influence which fat exerts upon the gastric 
secretion. 

The conditions which affect the carbohydrate-fat demand in health are 
essentially the same as those which modify the total requirement of energy, 
and have already been considered under the Total Food Requirement, It 
may be added, however, that the amount of fat consumed is generally 
less in hot climates and in hot weather. The reason popularly assigned is 
that fat is “heating.” Rubner has shown that a greater amount of free 
heat is liberated during the metabolism of fat than during the metabolism 
of carbohydrates. Physicians generally advise patients who are taking 
fat medicinally, for example, cod-liver oil, to discontinue it in hot weather. 
Negroes form an exception to the rule that peoples living in farm cli¬ 
mates eat little fat. They enjoy and consume fat in relatively large 
quantities. 

Too little is known concerning the fat requirement in various diseases 
to justify specific recommendations. The fat in the food is increased 
when it is desired to have a patient put on flesh. Fat appears to possess, 
along with carbohydates, the power of diminishing the febrile destruction 
of protein. 

The Injurious Effects of an Excess of Fat . Q —The tolerance for fat, 
both as regards quantity and kind, varies in health. Many persons 
cannot take much fat, or certain fats, without experiencing a feeling of 
disgust which may amount to nausea. In addition, fat is capable of pro¬ 
ducing certain well-defined local disturbances of the alimentary tract, 


5 See Table on page 95. 

8 The phrase “excess of fat” must be understood to relate to the tolerance of the 
individual rather than to the total amount of fat consumed. 



94 


NUTRITION AN 13 DIETETICS 


which may be confined to the stomach or to the intestines. The com¬ 
moner disorders are loss of appetite, nausea after taking food, and vomit¬ 
ing. These effects are probably due to the inhibitory action of fat upon 
the gastric secretion, or to the delay which it causes in the passage of the 
chyme into the duodenum. Regurgitation of the duodenal contents into 
the stomach sometimes occurs, and is usually followed by vomiting. An 
excess of fat often causes diarrhea. 

Besides these local actions, an excess of fat is believed by many author¬ 
ities to cause disorders of metabolism. Persons otherwise in perfect 
health sometimes develop acne when the food contains much fat, but 
whether this results from a disturbance of metabolism, or of digestion, is 
not known. 

It has been asserted that an excess of fat is of itself capable of caus¬ 
ing acidosis, but such a general assertion must be accepted with reserve. 
Deprivation of carbohydrate is followed by acidosis in disease as well as 
in health because of the increased demand for energy which falls upon 
fat, and its consequent incomplete combustion. Acidosis of this character 
has been observed to disappear spontaneously, and always disappears in 
healthy persons, upon the addition of carbohydrate to the diet, as sufficient 
carbohydrate prevents the formation of ketone bodies. The influence 
of starvation upon the development of acidosis has sometimes been 
overlooked, and the condition has been attributed erroneously to the fat 
of the food or to the effect of the disease itself. For example, doubt has 
been cast upon the causative relation of fat to the “cyclic” vomiting of 
children. Magnus-Levy has pointed out that the cause of acidosis in 
diabetes mellitus is not the fat of the food, but the preexisting disorder 
of metabolism. Fat in amounts up to 250 grams a day does not cause 
acidosis in typhoid fever. 

Czerny and Steinitz believe that the majority of cases of acidosis 
in children are due to an excess of fat. In experiments made upon 
children by Czerny and Keller, fat was the only foodstuff which in¬ 
creased the ammonia excretion in the urine. Steinitz has advanced the 
theory that the development of acidosis with fatty acid stools in the gastro¬ 
intestinal disorders of children, especially the chronic forms, is due to the 
loss of fixed alkalis through the intestines, either in their own form or in 
combination with fatty acids, that is, such as soaps. Bahrdt considers that 
the increase of alkali in the stools is due to the stimulating influence 
of fat upon the pancreas and the intestinal secretions; that there is not 
enough fatty acid present to account for all of the bases. According to 
Freund, there are but few tenable arguments and no absolutely certain 
metabolic-chemical facts to support the clinical impression of a causative 
relation between fat and acidosis. Yet for the present it seems advisable 
to be guided by clinical experience, and to withhold fat, or give it with 
caution, in the gastro-intestinal disorders of children. 


FOOD EATTOS 


95 


The generally accepted ratios of protein, carbohydrate, and fat for per¬ 
sons at light, moderately hard, and hard work are contained in the fol¬ 
lowing table: 

Standard Rations 



Voit 

Rubner 

Atwater 

Light Work 




Protein, grams. 

.... 

123 

100 

Fat, grams . 

.... 

46 

* 

Carbohydrate, grams .... 

.... 

377 

* 

Calories . 

.... 

2,445 

2,700 

Moderately Hard Work 




Protein, grams. 

118 

127 

125 

Fat, grams . 

56 

52 

* 

Carbohydrate, grams . .. 

500 

509 

* 

Calories . 

3,055 

2,968 

3,400 

Hard Work 




Protein, grams. 

145 

165 

150 

Fat, grams. 

100 

70 

* 

Carbohydrate, grams . .. 

500 

565 

* 

Calories . 

3,574 

3,362 

4,150 


* Fat and carbohydrate must be supplied in sufficient quantities to make up the necessary 


, energy. 

It must be pointed out that these figures represent averages obtained 
by calculations from estimations of food actually eaten by a group of 
individuals. Such figures will, of course, allow for certain individual 
fluctuations on either side of the average figures, which, however, as a 
general measure may be accepted with considerable confidence. 

Method of Reckoning the Protein, Fat and Carbohydrate Ratios for 
Diets of Definite Energy Values. —In Voit’s standard diet for a man at 
moderately hard work, approximately 16 per cent of the energy is 
furnished by protein, 18 per cent by fat, and 66 per cent by carbohydrate. 
With the total energy value of the diet as 3,000 calories, the calculation is 
made as follows: 

16 per cent of 3,000 =-^-= 115 grams protein. 


540 

18 per cent of 3,000-jj-g - — 


k.1 — 


66 per cent of 3,000 =-^y = 483 S rams carbohydrate. 

By the employment of this method, the ratios may be determined for 
diets of any given energy value. 



















96 


NUTRITION AND DIETETICS 


Composition of Foods 

Slightly modified from Atwater and Bryant, U. S. Dept. Agriculture , 
Bull. No. 28 (revised edition) 


Food Materials 

Per Cent 
Protein 
(N. x 6.25) 

Per Cent 
Fat 

Per Cent 
Carbo¬ 
hydrates 

Fuel 

Value 

per 

Pound 

in 

Calories 

Fuel 
Value 
per 100 
Grams 
in 

Calories 

100- 

Calory 

Por¬ 

tions 

in 

Grams 

Animal Food 







Beef, Fresh 







Loin, lean, E.P.*. 

13.0—24.0 

11.0—15.0 


900 

199 

52.5 

Loin, medium fat. 

11.0—22.0 

16.0—24.0 


1,190 

262 

38.2 

Loin, fat. 

16.0—19.0 

25.0—30.0 


1,490 

329 

30.4 

Loin, average. 

19.0 

19.1 


1,155 

254 

39.4 

Loin, porterhouse steak 

21.9 

20.4 


1,270 

270 

37.0 

Loin, sirloin steak. 

18.9 

18.5 


1,130 

250 

40.0 

Loin, tenderloin. 

12.0—18.0 

17.0—30.0 


1,330 

290 

34.5 

Ribs, lean. 

16.0—21.0 

10.0—14.0 


870 

190 

52.6 

Ribs, medium fat. 

16.0—19.0 

18.0—33.0 


1,450 

320 

31.2 

Ribs, fat. 

12.0—17.0 

34.0—37.0 


1,780 

390 

25 6 

Ribs, average. 

17.8 

24.6 


1,370 

300 

AO 

33.4 

Rump, lean. 

17.0_23.0 

10.0—18.0 


965 

210 

47 6 

Rump, medium fat. .. . 

16.0—19.0 

20.0—30.0 


1,400 

310 

Tl .U 

32.3 

Rump, fat. 

15.0—23.0 

33.0—39.0 


1,820 

400 

95 0 

Rump, average. 

18.7 

23.1 


1,325 

290 

£0*\J 

Beef liver. 

18.0—23.0 

3.0— 6.0 

1.0— 3.5 

’605 

135 

UT.U 

74.0 

Beef marrow. 

2.2 

92.8 


3,955 

870 

11 5 

Beef tongue. 

17.0—22.0 

1.0—18.0 


740 

165 

60.6 

Veal, Fresh 




Leg, lean. 

20.0—23.0 

1.0— 6.0 


570 

125 

80 0 

Leg, medium fat. 

*18.0—21.0 

7.0—12.0 


755 

165 

OU.u 

60 6 

Loin, lean. 

19.0—21.0 

5.0— 7.0 


615 

135 

uu.u 

74 1 

Loin, medium fat. 

18.0—20.0 

10.0—13.0 


825 

180 

55 6 

Loin, fat. 

18.0—19.0 

18.0—19.0 


1145 

9^0 

40 O 

Loin, average. 

19.9 

10.0 


790 

ZO\J 

175 

4U.U 

KV 0 

Rib, medium fat. 

20.0—22.0 

3.0— 9.0 


640 

X 1 O 

140 

O i ,z 

Vi 4 

Rib, fat. 

16.0—20.0 

H.0—31.0 


1 160 

X*rU 

900 

l 1.4 

QQ A 

Veal kidney, average. . 

16.9 

6.4 


IjlUV 

585 

130 

00.4: 

77.0 

Veal liver, average. .. . 

19.0 

5.3 


575 

125 

80.0 

Lamb, Fresh 







Leg. 

15.0—18.0 

15.0—27.0 


1 300 

9Q0 

QA K 

Loin. 

17.0—20.0 

25.0—35.0 


1,540 

ZOVJ 

340 

o4.o 

29.4 

Mutton, Fresh 




Leg, lean. 

19.0—20.0 

12.0 — 13.0 


RQO 


('1 Q 

Leg, medium' fat. 

17.0—10.0 

15.0—22.0 


Ot/U 

110^> 

iyo 

940 

51.o 

Leg, average. 

18.7 

17.5 



O/t fl 

41. < 

41.7 

0/3 

Loin, medium fat. 

14.0—20.0 

26.0—38.0 


ljUOt) 


Loin, free fat removed. 
Kidney. 

23.7 

16.5 

18.5 

3.2 


1,225 

A A A 

o l O 

270 

(\br 

zo.7 

37.0 

Liver, average. 

23.1 

9.0 

5.0 

905 

200 

103.0 

50.0 


* Edible Portion. 














































































COMPOSITION OF FOODS 


97 


Food Materials 


Animal Food—Cont. 

Pork, Fresh 

Chops, medium fat. .. . 

Chops, fat. 

Ham, smoked, lean. .. . 
Ham, smoked, medium 

fat. 

Ham, smoked, fat. 

Ham, smoked, average. 
Bacon, medium fat. ... 
Sausages 

Bologna . 

Frankfort . 

Pork. 

Poultry, etc., Fresh 

Chicken, broilers. 

Fowls . 

Turkey. 

Chicken liver. 

Fish, Fresh 

Bass, black, average. .. 
Bass, striped, average.. 

Bluefish . 

Cod . 


Mackerel . 

Salmon, average., 
Shad, average.... 

Shad, roe. 

Fish, Preserved 
Canned 

Cod, salt, boneless 

average . 

Mackerel, salt, boneless 

average . 

Sardines . 

Caviare . 

Shellfish, etc., Fresh 

Clams. 

Lobsters. 

Oysters . 

Scallops, average. 

Crabs . 

Meats, Cooked 

Beef, roast. 

Beef, round s' 
roasted . 


Per Cent 
Protein 
(N. x 6.25) 

Per Cent 
Fat 

Per Cent 
Carbo¬ 
hydrates 

Fuel 

Value 

pe 

Pound 

in 

Calories 

Fuel 
Value 
per 100 
Grams 
in 

Calories 

100- 

Calory 

Por¬ 

tions 

in 

Grams 

14 . 0 — 19.0 

25 . 0 — 35.0 


1,580 

350 

28.6 

11 . 0 — 19.0 

39 . 0 — 49.0 


2,145 

470 

21.6 

19 . 0 — 20.0 

17 . 0 — 24.0 


1,245 

280 

35.7 

12 . 0 — 23.0 

30 . 0 — 45.0 


1,940 

430 

23.6 

12 . 0 — 19.0 

42 . 0 — 57.0 


2,485 

550 

18.2 

16.5 

38.8 


1,945 

430 

23.6 

6 . 0 — 18.0 

57 . 0 — 80.0 


3,030 

670 

14.9 

15 . 0 — 21.0 

11 . 0 — 24.0 

0 . 2 — 0.5 

1,095 

240 

41.7 

15 . 0 — 27.0 

15 . 0 — 26.0 

2 . 0 — 8.6 

1,170 

260 

38.5 

7 . 0 — 19.0 

28 . 0 — 57.0 

0 . 0 — 8.6 

2,125 

470 

21.6 

19 . 0 — 25.0 

2 . 0 — 4.0 


505 

110 

91.1 

15 . 0 — 22.0 

10 . 0 — 28.0 


1,045 

230 

43.5 

19 . 0 — 25.0 

9 . 0 — 31.0 


1,360 

300 

33.4 

22.4 

4.2 

2.4 

640 

140 

71.4 

20.6 

1.7 


455 

100 

100.0 

18.6 

2.8 


465 

105 

95.2 

19.4 

1.2 


410 

91 

109.9 

15 . 0 — 18.0 

0 . 3 — 0.5 


325 

72 

138.9 

; 18.6 

5.2 


565 

125 

80.0 

17 . 0 — 19.0 

2 . 0 — 16.0 


645 

140 

71.4 

22 0 

12.8 


950 

210 

47.7 

18.8 

9.5 


750 

165 

60.6 

20.9 

l 

3.8 

2.6 

600 

135 

74.1 

27 3 

0.3 


490 

110 

90.9 

1 Y 3 

26.4 


1,435 

320 

31.2 

X i .t) 

23 0 

19.7 


1,260 

280 

35.7 

30.0 

19.7 


1,530 

340 

29.4 

8 . 0 — 9.0 

1 . 0 — 1.2 

1 . 0 — 2.0 

240 

53 

189.0 

12 . 0 — 25.0 

1 . 0 — 2.0 

0 . 0 — 1.0 

390 

86 

116.2 

4 . 0 — 10.0 

0 . 6 — 7.0 

2 . 0 — 7.0 

235 

52 

192.2 

14.8 

0.1 

3.4 

345 

76 

131.5 

16.6 

2.0 

1.2 

415 

92 

108.6 

i k o_99 0 

20 . 0 — 41.0 


1,620 

360 

27.8 

i Id. v A •\J 

19 . 0 — 34.0 

3 . 0 — 17.0 

i 

840 

185 

54.1 




































































98 


NUTRITION AND DIETETICS 


Food Materials 

Per Cent 
Protein 
(N. x 6.25) 

Per Cent 
Fat 

Per Cent 
Carbo¬ 
hydrates 

Fuel 

Value 

per 

Pound 

in 

Calories 

Fuel 
Value 
per 100 
Grams 
in 

Calories 

100 - 

Calory 

Por¬ 

tions 

in 

Grams 

Animal Food—Cont. 







Meats, Cooked—Cont. 







Loin steak, tenderloin. 







broiled . 

20.0—27.0 

12.0—36.0 


1,300 

290 

34.5 

Corn beef, canned... . 

21.0—35.0 

12.0—31.0 


1,280 

280 

35.7 

Tongue, canned. 

11.0—23.0 

16.0—33.0 


1,340 

300 

33.3 

Lamb, Cooked 





Chops, broiled. 

190—25.0 

24.0—35.0 


1,665 

370 

27.1 

Leg, roast. 

19.7 

12.7 


900 

200 

50.0 

Mutton, Cooked 






Leg, roast. 

23.0—28.0 

28.0—25.0 


1,420 

310 

32.3 

Pork, Cooked 



Ham, roast. 

18.0—26.0 

17.0—24.0 


1,210 

281 

35.6 

Ham, smoked, boiled. . 

18.0—22.0 

8.0—37.0 


1,320 

290 

34.5 

Ham, smoked, fried. .. 

22.2 

33.2 


1,815 

400 

25.0 

Ham, luncheon, cooked 

22.5 

21.0 


1,305 

290 

34.5 

Poultry, Cooked 







Capon. 

27.0 

11.5 


985 

220 

45.5 

Chicken, fricasseed. .. 

17.6 

11.5 

2.4 

855 

190 

52.6 

Turkey, roast. 

27.8 

18.4 


1,295 

290 

34.5 

Fish, Cooked 


Bluefish, cooked. 

25.9 

4.5 


670 

150 

66.6 

Spanish mackerel 




broiled . 

23.7 

6.5 


655 

145 

69.0 

Hairy Products 



Eggs, hen’s, raw, E.P. 

11.6—16.0 

8.6—15.1 


720 

160 

62.5 

Eggs, hen’s, boiled. ... 

10.0—15.6 

9.1—14.7 


765 

170 

58.8 

Eggs, hen’s, average. .. 

13.3 

11.2 


742 

165 

60.6 

Eggs, boiled, whites... 

11.6—14.8 

0.0— 0.3 


250 

55 

182.0 

Eggs, boiled, yolks.... 

15.3—16.8 

32.2—34.4 


1,705 

380 

26.3 

Putter . 

1.0 

85.0 


3,605 

800 

12.5 

Milk, buttermilk. 

3.0 

0.5 

4.8 

165 

36 

278.0 

Cheese, American. 

28.8 

35.9 

0.3 

2,055 

450 

22.2 

Cheese, Cheddar. 

27.7 

36.8 

4.1 

2,145 

470 

21.3 

Cheese, Cottage. 

16.0—20.0 

0.4— 1.6 

3.7— 4.9 

510 

115 

87.0 

Cheese, Hutch. 

30.0—45.0 

16.0—19.0 


1,435 

320 

31.2 

Cheese, full cream.... 

18.0—37.0 

24.0—45.0 

1.2— 4.0 

1,950 

430 

23.2 

Cheese, Swiss. 

26.0—29.0 

33.0—37.0 

0.9— 1.7 

2,010 

440 

22.7 

Koumiss. 

2.6— 3.0 

1.7— 2.4 

5.1— 5.9 

240 

53 

189.0 

Milk, sweetened, con¬ 







densed . 

6.0—10.0 

0.4—10.6 

44.0—57.0 

1,520 

340 

29.4 

Milk, unsweetened, con¬ 







densed (evaporated 







milk) . 

8.0—10.0 

8.0—10.0 

10.0—12.0 

780 

170 

58.8 

Milk, skimmed. 

3.4 

0.3 

5.1 

170 

38 

263.0 


























































COMPOSITION OF FOODS 


Food Materials 

Per Cent 
Protein 
(N. x 6.25) 

Per Cent 
Fat 

Per Cent 
Carbo¬ 
hydrates 

Fuel 

Value 

per 

Pound 

in 

Calories 

Fuel 
Value 
per 100 
Grams 
in 

Calories 

100- 

Calory 

Por¬ 

tions 

in 

Grams 

Animal Food—Cont. 

Dairy Products—Cont. 







Milk, whole. 

3.3 

4.0 

5.0 

325 

72 

138.9 

Whey . 

1.0 

0.3 

5.0 

125 

28 

357.0 

Woman’s milk*. 

2.01 

3.74 

6.37 

310 

68 

147.1 

Goat’s milk*. 

3.76 

4.07 

4.64 

315 

69 

144.0 

Cream * . 

Cream, very rich, cen- 

2.5 

18.5 

4.5 

935 

206 

■48.6 

' 1 

trifugal f. 

Cream, ordinary, cen- 

2.2 

40.0 

3.0 

1,780 

393 

25.4 

trifugal f. 

3.0 

20.0 

3.9 

925 

204 

49.1 

Cream, ordinary, grav- 







ityf . 

3.0— 3.2 

16.0—20.0 

3.9— 4.0 

890 

196 

51.0 

Milk, ordinary, whole f 

3.5 

4.0 

4.5 

320 

70 

143.0 

Top from one quart of 
whole milk f: 

Top 16 oz. or upper 







one-half. 

3.4 

7.0 

4.5 

440 

98 

100.2 

Top 11 oz. or upper 







one-third . 

3.3 

10.0 

4.3 

560 

124 

80.7 

Top 8 oz. or upper 







one-fourth. 

3.3 

13.0 

4.2 

670 

148 

67.6 

Top 6 oz. or upper 







one-fifth. 

3.2 

16.0 

4.0 

805 

178 

56.2 

Whey from whole 







milk *. 

0.94 

0.96 

5.5 

115 

25 

400.0 

Whey from fat-free 







milk^: . 

1.17 

0.04 

5.4 

120 

27 

370.5 

Matzoon or Zoolakf.. 
Gelatin . 

3.5 

89.0—97.0 

3.5 

3.7 

280 

1,705 

405 

4,220 

4,010 

3,525 

62 

380 

161.2 

26.3 

111.1 

10.7 
11.2 

12.8 

Calf’s foot jelly. 

Lard, refined. 

4.3 

100.0 

92 0_96 0 

17.4 

90 

930 

890 

780 

Lard, unrefined . 

2.0— 3.0 


Oleomargarine. 

1.2 

83.0 


Beef-juice . 

Vegetable Food 

4.9 

0.6 


115 

25 

400.0 

Barley, meal and flour. 

9.0—13.0 

1.5— 3.2 

70.0—74.0 

1,640 

360 

27.8 

Bariev nearled. 

7.0—10.0 

0.09 

0 7— 1 5 

77 o—78 0 

1,650 

36 

360 

8 

27.8 

1250. 

Barley water f . 

0.05 

1.6 

Buckwheat, flour 

4.0—10.0 

0 5— 2 3 

71 0—81 0 

1,620 

360 

27.8 

Buckwheat prepara- 



tions, farina, and 







groats, average. 

10.9 

0.4 

84.0 

1,660 

370 

27.1 

Corn-meal, unbolted. .. 

8.0— 9.0 

4.5— 5.2 

72.0—75.0 

1,730 

380 

26.3 

Corn-flour. 

6 .0— 8.0 

1 .0— 2.0 

77.0—80.0 

1,645 

360 

27.8 


* From U. S. Dept, of Agriculture Farmers’ Bulletin No. 363. 
f From Holt, The Diseases of Infancy and Childhood, New York, 1904. 
X From Analyses by Adriance. 



























































100 


NUTRITION AND DIETETICS 


Food Materials 

Per Cent 
Protein 
(N. x 6.25) 

Per Cent 
Fat 

Per Cent 
Carbo¬ 
hydrates 

Fuel 

Value 

per 

Pound 

in 

Calories 

Fuel 
Value 
per 100 
Grams 
in 

Calories 

100- 

Calory 

Por¬ 

tions 

in 

Grams 

Vegetable Food—Cont. 

Corn-meal, granular. .. 

7.0—12.0 

1.0— 5.0 

68.0—80.0 

1,655 

370 

27.1 

Hominy, raw. 

6.0— 9.0 

0.2— 1.0 

77.0—81.0 

1,650 

360 

27.8 

Hominy, cooked. 

2.2 

0.2 

17.8 

380 

84 

119.0 

Oatmeal, raw. 

13.0—21.0 

6.0— 9.0 

64.0—70.0 

1,860 

410 

24.4 

Oatmeal, boiled. 

2.8 

0.5 

11.5 

285 

63 

159.0 

Oatmeal, gruel. 

0.9— 1.6 

0.2— 0.5 

3.0—10.0 

155 

34 

294.0 

Oatmeal water. 

0.4— 0.9 

0.0— 0.1 

1.3— 4.5 

70 

15 

666.6 

Rice . 

5.9—11.3 

0.1— 0.7 

75.4—81.9 

1,630 

360 

27.8 

Rice, boiled. 

1.6— 5.0 

0.0— 0.1 

15.5—41.9 

510 

115 

86.9 

Rye flour. 

4.9— 8.8 

0.2— 1.3 

77.6—80.2 

1,630 

360 

27.8 

Wheat flour. 

12.2—14.6 

2.1— 1.5 

69.5—77.0 

1,675 

370 

27.1 

Wheat flour, patent 
roller process. 

8.4—14.7 

0.3— 1.6 

70.3—80.0 

1,660 

370 

27.1 

Farina . 

10.4—11.7 

0.8— 3.8 

74.6—78.5 

1,685 

370 

27.1 

Shredded wheat. 

9.6—11.4 

1.3— 1.6 

75.0—79.7 

1,700 

380 

26.3 

Macaroni. 

7.9—16.6 

0.0— 4.9 

67.2—78.4 

1,665 

370 

27.1 

Bread, brown, as pur¬ 
chased . 

5.0— 5.8 

1.2— 2.4 

43.6—50.7 

1,050 

230 

43.5 

Bread, corn (johnny 
cake) . 

6.5—10.1 

2.3— 9.8 

40.3—54.3 

1,205 

280 

35.7 

Bread, rye. 

6.4—11.1 

0.1— 1.4 

45.6—65.8 

1,180 

260 

38.4 

Bread, gluten. 

8.2—11.1 

0.7— 2.4 

44.6—53.0 

1,160 

260 

38.4 

Bread, graham. 

6.8—10.9 

0.4— 3.8 

38.6—59.1 

1,210 

270 

37.1 

Rolls, plain. 

8.6—11.9 

0.4— 9.4 

56.7—64.7 

1,470 

320 

31.2 

Rolls, all analyses, 
average • . 

8.9 

4.1 

56.7 

1,395 

310 

32.3 

Toasted bread. 

10.6—12.8 

0.6— 3.2 

56.7—67.1 

1,420 

310 

32.3 

Bread, white, home¬ 
made . 

6.8—11.0 

0.4— 3.5 

47.6—58.0 

1,225 

270 

37.1 

Bread, white, all analy¬ 
ses, average. 

9.2 

1.3 

53.1 

1,215 

270 

37.1 

Bread, whole wheat. .. 

8.1—11.7 

Q 4_ 2.7 

37.2—56.2 

1,140 

250 

40.0 

Zwieback . 

8.6—11.7 

8.1—11.3 

72.1—74.2 

1,970 

435 

23.0 

Crackers, Boston, split 

10.7—11.3 

9.9 

68.8—73.4 

1,885 

415 

24.1 

Crackers, cream. 

8.6—11.2 

10.7—13.8 

68.0—72.4 

1,990 

440 

22.8 

Crackers, graham. 

7.4—14.4 

1.1—13.6 

69.7—77.2 

1,955 

430 

23.2 

Crackers, oatmeal. 

10.4—13.1 

8.5—13.7 

68.3—69.6 

1,970 

435 

23.0 

Crackers, saltines. 

9.9—11.2 

12.7—12.8 

67.1—69.9 

2,005 

440 

22.8 

Cake, chocolate layer.. 

6.2 

8.1 

64.1 

1,650 

365 

27.5 

Cake, coffee. 

4.9— 9.0 

4.7—10.5 

52.4—78.8 

1,625 

360 

27.8 

Cake, cup. 

5.2— 6.6 

2.5—15.6 

63.2—73.8 

1,765 

390 

25.6 

Cake, frosted. 

5.0— 7.5 

7.5—10.6 

58.3—71.0 

1,695 

375 

26.7 

Gingerbread . 

5.4— 6.3 

8.4— 9.5 

62.3—64.7 

1,670 

370 

27.1 

Cake, sponge. 

5.7— 7.3 

6.4—13.0 

57.3—71.1 

1,795 

395 

25.3 

Cake, all analyses ex¬ 
cept fruit cake, aver¬ 
age . 

6.3 

9.0 

63.3 

1,675 

370 

27.1 















































COMPOSITION OF FOODS 


101 


Food Materials 

Per Cent 
Protein 
(N. x 6.25) 

Per Cent 
Fat 

Per Cent 
Carbo¬ 
hydrates 

Fuel 

Value 

per 

Pound 

in 

Calories 

Fuel 
Value 
per 100 
Grams 
in 

Calories 

100- 

Calory 

Por¬ 

tions 

in 

Grams 

Vegetable Food—Cont. 







Cookies, all analyses, 







average . 

7.0 

9.7 

73.7 

1,910 

420 

23.8 

Ginger snaps. 

5.8— 7.3 

2.3—15.4 

71.9—80.8 

1,895 

420 

23.8 

Macaroons. 

3.1—10.6 

9.6—21.5 

57.1—71.4 

1,975 

435 

23.0 

Doughnuts . 

5.1— 7.6 

16.4—25.7 

45.8—63.2 

2,000 

440 

22.8 

Pie, apple. 

2.6— 3.8 

7.7—11.3 

40.3—46.2 

1,270 

280 

35.7 

Pie, custard. 

4.2 

6.3 

26.1 

830 

180 

55.6 

Pie, mince. 

4.5— 7.5 

9.7—14.5 

30.4—44.0 

1,335 

295 

34.0 

Pie, squash. 

4.4 

8.4 

21.7 

840 

185 

54.1 

Pudding, Indian-meal. 

5.5 

4.8 

27.5 

815 

180 

55.6 

Pudding, rice custard. 

4.0 

4.6 

31.4 

825 

180 

55.6 

Pudding, tapioca. 

2.8— 4.2 

2.3— 4.8 

21.9—38.1 

720 

160 

62.5 

Pudding, tapioca with 







apples. 

0.3 

0.1 

29.3 

555 

125 

80.0 

Candy . 



96.0 

1,785 


ok ^ 

Honey . 

0 . 2 — 1.1 


77.3 _85.4 

1 590 

ovo 

350 

9ft ft 

Molasses . 

0.0— 5.1 

0 . 0 — 0.2 

58.8—76.7 

L290 

285 

Li 0.0 

35.1 

Starch, arrowroot. 



97.5 

1 815 

400 

25.0 

Starch, cornstarch.... 

. 


90.0 

1*675 

370 

27.1 

Starch, tapioca. 

0 . 2 — 0.6 

0.0— 3.0 

86 6 _89 0 

1,650 

qck 


Sugar, coffee or brown 


95.0 

1,765 

ODt) 

390 

Li { .O 

25.6 

Sugar, granulated. 

.. 


100.0 

1*860 

410 

24.4 

Sugar, maple . 



74.0 _ 95.2 

1 540 

340 

29.4 

Syrup, maple . 



45.9—81.9 

1*330 

295 

34.0 

Vegetables 



Artichokes . 

2.2— 2.9 

0 . 1 — 0.2 

15.3—18.3 

365 

81 

123.3 

Asparagus, cooked. ... 

2.1 

3.3 

2.2 

220 

49 

204.0 

Beans, butter, green, 







E. P . 

9.4 

0.6 

29.1 

740 

165 

60.6 

Beans, dried . 

19.9—26.6 

1.4— 3.1 

57.2—63.5 

1,605 

355 

28.1 

Beans, lima, dried. ... 

12.8—24.5 

0.6— 1.9 

61.6—70.1 

1,625 

360 

27.8 

Beans, lima, fresh, 







E. P . 

3.2 

0.3 

9.9 

255 

56 

178.7 

Beans, string, cooked 







E. P. 

0.8 

1.1 

1.9 

95 

21 

477.0 

Beans, string, fresh 







E. P. 

1.7— 2.8 

0.4 

12.6 

300 

66 

151.5 

Beets, cooked, E. P. .. 

2.3 

0.1 

7.4 

185 

41 

244.0 

Beets, fresh, E. P. 

0.9— 3.0 

0 . 1 — 0.2 

3.8—16.3 

215 

47 

216.0 

Cabbage, E. P. 

0.2— 2.9 

0 . 1 — 0.7 

3.4— 8.0 

145 

42 

238.0 

Carrots, fresh, E. P. .. 

0.7— 2.0 

0 . 0 — 0.7 

6.5—13.8 

210 

46 

218.0 

Cauliflower. 

1 . 6 — 2.0 

0 . 2 — 8.0 

3.4— 6.0 

140 

31 

323.0 

Celery, E. P. 

1.0— 1.4 

0 . 1 — 0.2 

3.0— 4.6 

85 

19 

526.0 

Corn, green, E. P. 

2 . 8 — 3.7 

1 . 0 — 1.1 

14.1—22.6 

470 

105 

95.4 

Cucumbers, E. P. 

0.5— 0.9 

0.1— 0.5 

2.2— 4.0 

80 

18 

556.0 

Lentils, dried. 

24.5—26.6 

0.7— 1.5 

58.6—59.8 

1,620 

360 

27.8 































































102 


NUTRITION AND DIETETICS 


Food Materials 

Per Cent 
Protein 
(N. x 6.25 

Per Cent 
Fat 

Per Cent 
Carbo¬ 
hydrates 

Fuel 

Value 

per 

Pound 

in 

Calories 

Fuel 
Value 
per 100 
Grams 
in 

Calories 

100- 

Calory 

Por¬ 

tions 

in 

Grams 

Y egetables—Cont. 

Lettuce, E. P . 

0.7— 1.8 

0.1— 0.6 

1.6— 4.9 

90 

20 

500.0 

Mushrooms . 

1.7— 6.0 

0.2— 0.9 

2.4—20.3 

210 

46 

218.0 

Onions, fresh, E. P. .. 

0.2— 4.4 

0.1— 0.8 

4.2—15.5 

225 

50 

200.0 

Onions, cooked, pre¬ 
pared . 

1.2 

1.8 

4.9 

190 

42 

238.0 

Parsnips . 

1.4— 1.9 

0.2— 0.8 

8.0—17.0 

300 

66 

151.5 

Pons dried . . 

20.4—28.0 

0.8— 1.3 

58.0—67.4 

1,655 

465 

365 

27.5 

Peas, green, E. P. 

4.4— 8.0 

0.3— 0.6 

13.4—18.9 

105 

95.4 

Peas, green, cooked... 

6.7 

3.4 

14.6 

540 

120 

83.3 

Potatoes, raw or fresh, 
E. P. 

1.1— 3.0 

0.0— 0.2 

13.5—27.4 

385 

85 

117.8 

Potatoes, cooked, boiled 

1.8— 3.1 

0.0— 0.4 

16.1—26.5 

440 

97 

103.1 

Potatoes, cooked, chips 

6.0— 7.6 

35.5—44.2 

42.7—50.6 

2,675 

590 

16.9 

Potatoes, cooked, 

mashed and creamed 

2.0— 3.6 

1.0— 4.5 

13.9—22.4 

505 

110 

90.9 

Potatoes, sweet, raw or 
fresh, E. P. 

0.4— 3.7 

0.2— 1.4 

17.1—49.1 

570 

125 

80.0 

Potatoes, cooked and 
prepared, sweet. 

3.0 

2.1 

42.1 

925 

200 

50.0 

Sweet cassava *. 

1.1 

0.2 

30.2 

610 

135 

74.1 

Cassava starch*. 

0.5 

0.1 

88.8 

1,625 

360 

27.8 

Cassava bread*. 

9.1 

0.3 

79.0 

1,650 

365 

27.4 

Cassava cakes or 
wafers*.•. 

« 

1.1 

0.2 

85.2 

1,670 

370 

27.0 

Taro * . 

1.8 

0.2 

23.2 

475 

105 

95.3 

Yams*. 

1.8 

0.2 

23.3 

475 

105 

95.3 

Yautia tubers*. 

2.2 

0.2 

26.1 

535 

120 

83.3 

Radishes, E. P. 

0.5— 3.0 

0.0— 0.3 

3.4— 8.3 

135 

30 

334.0 

Spinach, fresh. 

1.8— 2.4 

0.2— 0.5 

3.1— 3.4 

110 

24 

117.0 

Spinach, cooked. 

2.1 

4.1 

2.6 

260 

57 

175.4 

Squash, E. P. 

0.6— 3.1 

0.1— 1.4 

3.5—16.5 

215 

47 

216.0 

Tomatoes, fresh. 

Turnips . 

0.3— 1.3 
0.7— 3.9 

0.2— 1.4 
0.1— 0.4 

2.2— 6.5 
2.8—23.8 

105 

185 

23 

41 

435.0 

244.0 

Vegetables, Canned 
Asparagus. 

0.9— 2.4 

0.0— 0.2 

2.2— 4.1 

85 

19 

526.0 

Beans, baked. 

5.1— 8.1 

0.3— 6.8 

13.1—23.2 

600 

135 

74.0 

Beans, string. 

0.6— 4.0 

0.0— 0.5 

2.0—13.5 

95 

21 

177.0 

Beans, lima.. . 

3.2 — 5.6 

0.2— 0.6 
0.5— 1.9 

10.5—17.9 

9.8—25.8 

360 

79 

100 

126 7 

Corn, green. 

2.0— 3.7 

uuv 

455 

iLfv, | 

100.0 

Peas, green. 

1.6— 6.1 

0.0— 0.8 

4.9—17.4 

255 

56 

178.5 

Succotash . 

2.9— 4.4 

0.7— 1.7 

14.9—22.4 

455 

100 

100.0 

Tomatoes. 

0.3— 1.7 

0.1— 0.3 

1.4— 8.1 

105 

23 

435.0 

Catsup, tomato. 

1.1— 2.0 

0.1— 0.4 

8.5—16.1 

265 

58 

172.3 

Olives, green, E. P. .. . 

1.1 

27.6 

11.6 

1,400 

310 

32.3 

Pickles, cucumber. .. . 

0.4— 0.7 

0.1— 0.5 

1.3— 5.4 

70 

15 

366.6 


From Bulletin No. 295, Dept, of Agriculture. 











































COMPOSITION OF FOODS 


103 


Food. Materials 

Per Cent 
Protein 
(N. x 6.25) 

Per Cent 
Fat 

Per Cent 
Carbo¬ 
hydrates 

Fuel 

Value 

per 

Pound 

in 

Calories 

Fuel 
Value 
per 100 
Grams 
in 

Calories 

100- 

Calory 

Por¬ 

tions 

in 

Grams 

Fruits 







Apples . 

0 . 1 — 0.8 

0.1— 1.4 

8.8—21.3 

290 

64 

156.1 

Apricots, E. P. 

1.1 


13.4 

270 

60 


Bananas, yellow, E. P 

1 . 0 — 1.6 

0.0— 1.4 

16.3—29.8 

460 

100 

1UU.O 

100.0 

Blackberries . 

0.9— 1.5 

0.5— 2.9 

7.5—16.7 

270 

60 

166.8 

Ch p rri os E P 

0 7— 11 

0 8 — 0 8 

11,4 _ 20.6 

365 

81 

193 3 

Cranberries. 

0.4— 0.5 

0.4— 0.9 

9.3—10.9 

215 

47 

216.0 

Grapes, E. P. 

1.3 

1.6 

19.2 

450 

99 

111.1 

Lemons, E. P. 

0 . 8 — 1.1 

0.1— 1.5 

8.2— 9.0 

205 

45 

226.0 

Lemon juice. 



9.8 

180 

40 

250.0 

Oranges, E. P. 

0 . 8 — 1.1 

0.1— 0.3 

11.6—18.5 

240 

53 

189.0 


04— 0 9 

0 1 — 0.1 

9 . 3 — 9.4 

190 

42 

238.0 

Pears, E. P. 

0 . 6 — 0.6 

0 . 1 — 0.8 

14.1—14.2 

295 

65 

154.0 

Plums, E. P., average. 

1.0 


20.1 

395 

87 

115.0 

Prunes, E. P., average 

0.9 


18.9 

370 

82 

122.0 

Raspberries, red, E. P. 

1.0 


12.6 

255 

56 

178.5 

Strawberries, E. P. .. . 

0.6— 1.2 

0.4— 1.1 

4.4—12.3 

180 

40 

250.0 

Watermelon, E. P. ... 

0.3— 0.6 

0.1— 0.2 

6.5— 6.9 

140 

31 

323.0 

Fruits, Dried 







Apples . 

1.2— 2.5 

0.1— 5.0 

48.6—86.9 

1,350 

300 

33.4 

Currants, Zante. 

1.0— 4.7 

0.4— 4.7 

60.0—85.3 

1,495 

330 

30.3 

Figs . 

2 . 6 — 5.7 

0.3— 0.3 

68.3—83.1 

1.475 

325 

30.8 

Prune« E P. 

1.4— 3.2 


68.1—78.6 

1,400 

310 

32.3 

Fruits, Canned, etc. 






Raisins, E. P. 

2.3— 3.0 

0.5— 7.2 

71.3—78.8 

1,605 

355 

28.1 

Apple sauce. 

0.2 

0.8 

37.2 

730 

160 

62.5 

Marmalade (orange 







peel) . 

0.6 

0.1 

84.5 

1,585 

350 

28.6 

Strawberries, stewed. . 

0.7 


24.0 

460 

100 

100.0 

Nuts 







Almonds, E. P. 

16.6—25.3 

48.9—60.0 

12.8—21.4 

3,030 

670 

14.9 

Brazil nuts, E. P. .. . 

17.0 

66.8 

7.0 

3,265 

720 

13.9 

Chestnuts, fresh, E. P. 

4.1— 8.0 

2.0—10.8 

36.9—54.0 

1,125 

250 

40.0 

Coconut without milk. 

3.6 

31.7 

17.5 

1,730 

380 

26.3 

Filberts, E. P. 

15.6 

65.3 

13.0 

3,290 

725 

13.8 

Hickory nuts, E. P. .. 

15.4 

67.4 

11.4 

3,345 

740 

13.5 

Peanuts, E. P. 

19.5—29.1 

32.3—48.8 

15.3—40.4 

2,560 

565 

17.7 

Peanut-butter . 

29.3 

46.5 

17.1 

2,825 

625 

16.0 

Pecans, uhpolished. 







E. P. 

9.6 

70.5 

15.3 

3,435 

760 

13.1 

Walnuts, California, 







black, E. P. 

24.9—30.3 

54.7—57.8 

7.4—16.1 

3,105 

685 

14.6 

Miscellaneous 







Chocolate . 

12.5—13.4 

47.1—50.2 

26.8—33.8 

2,860 

630 

15.9 

Cocoa. 

20.6—22.7 

27.1—31.5 

35.3—40.6 

2,320 

510 

19.6 

Beef soup. 

2.7— 6.2 

0.3— 0.5 

0.0— 2.2 

120 

26 

384.0 

















































104 


NUTRITION AND DIETETICS 


Food Materials 

Per Cent 
Protein 
(N. x 6.25) 

Per Cent 
Fat 

Per Cent 
Carbo¬ 
hydrates 

Fuel 

Value 

per 

Pound 

in 

Calories 

Fuel 
Value 
per 100 
Grams 
in 

Calories 

100- 

Calory 

Por¬ 

tions 

in 

Grams 

Miscellaneous—Cont. 







Bean soup. 

3.2 

1.4 

9.4 

295 

65 

154.0 

Chicken soup . 

10.5 

0.8 

2.4 

275 

61 

164.0 

Clam chowder. 

0.7— 2.9 

0.5— 1.1 

2.5—11.0 

195 

43 

236.0 

Meat stew. 

3.7— 5.6 

2.0— 6.4 

4.3— 7.9 

370 

82 

122.0 

Soups, Canned 







Asparagus, cream of. . 

2.5 

3.2 

5.5 

285 

63 

159.0 

Bouillon . 

1.7— 2.6 

0 .0— 0.2 

0.1— 0.3 

50 

11 

909.0 

Celery, cream of. 

2.1 

2.8 

5.0 

250 

55 

182.0 

Chicken gumbo. 

3.0— 4.6 

0 .2— 1.7 

3.8— 5.5 

195 

43 

236.0 

Chicken soup. 

3.2— 3.9 

0 .0— 0.2 

1 .2— 1.7 

100 

22 

455.0 

Mock turtle. 

4.5— 5.9 

0.5— 1.3 

1.6— 3.9 

185 

41 

244.0 

Oxtail. 

3.9— 4.1 

0.5— 2.1 

4.2— 4.3 

210 

46 

218.0 

Pea soup. 

1.5— 5.8 

0 .0— 1.6 

5.1—11.1 

235 

52 

192.5 

Tomato soup. 

1.7— 1.9 

0.9— 1.2 

5.3— 6.0 

185 

41 

244.0 


THE EFFECTS OF COOKING UPON FOOD 7 

The practice of cooking food is universal. All existing races follow 
the custom, at least as regards part of their food, and archeological re¬ 
searches indicate that the art of cooking extended far into prehistoric 
times. Cooking plays an important part in the preparation of food for 
human consumption. Substances which in their natural state are insipid 
and nearly, or quite, indigestible become valuable foods when subjected 
to the processes of cooking. 

The objects sought in the cooking of meats and vegetables are essen¬ 
tially similar. They are as follows: 

1. To develop flavor and improve the appearance of the food. 

Eoods which are attractive in appearance, of pleasant aroma, and 

savory taste stimulate the secretion of the “appetite juice” and thus indi¬ 
rectly become more digestible. 

2 . To increase its digestibility. 

Cooking produces both physical and chemical changes in the food. It 
is more important in the case of vegetables than in th^ case of meats. 
Both are rendered more digestible. 

In the process of cooking the connective tissue of meat is softened 
and in part converted to gelatin. In consequence, mastication is easier 
and more complete, thus insuring freer access of the digestive juices to 

7 In the preparation of this section the author has derived much assistance from 
U. S. Dept, of Agriculture Bulls. Nos. 43, 67, and 102, and Farmers’ Bulls. Nos. 34 
and 389. 

























THE EFFECTS OF COOKING UPON FOOD 


105 


Percentage Composition of True and So-Called Gluten Plour 
From Wiley, Foods and Their Adulteration, Philadelphia, 1911 


Name 

Per Cent 

Per Cent 

Per Cent 

Protein 

Fat 

Carbohydrates 

Gum glutin (Hoyt’s). 

31.80 

1.55 

54.15 

Educator standard gluten flour. 

26.40 

1.67 

59.38 

Gluten flour, 40 per cent. 

40.25 

1.18 

47.42 


41.10 

1.10 

47.90 

Self-raising gluten flour, 40 per cent. .. . 

38.70 

1.30 

50.10 

Pure gluten flour. 

78.80 

0.90 

12.60 

20 per cent gluten flour. 

21.00 

0.70 

68.20 

Pure gluten flour, glutosac. 

35.20 

0.60 

55.00 

Gluten food. 

85.40 

0.56 

3.69 

Protosac . 

36.60 

0.86 

51.03 

Washed gluten flour. 

62.40 

0.91 

29.51 

Glutosac . 

34.06 

1.57 

52.13 

Diabetic biscuit flour. 

75.25 

8.96 

5.89 

Plasmon meal. 

78.65 

2.72 

0 . 

Aleuronat . 

86.10 

0.51 

4.00 


73.65 

0.24 

14.55 

Koborat. 

82.20 

3.67 

3.00 

Wheat protein. 

84.10 

1.40 

4.80 

Energin from rice. 

83.70 

4.54 

0.67 

Vegetable gluten. 

61.37 

1.55 

28.23 

Casoid flour. 

85.56 

0.50 

0 . 

Sanitas nut meal. 

29.00 

51.66 

12.13 

Soy bean meal. 

39.87 

19.06 

25.09 

Almond meal. 

50.62 

15.63 

15.90 

Gluten flour. 

11.37 

0.90 

74.38 

Gluten flour.• 

15.50 

2.60 

70.80 

Diabetic flour. 

12.00 

0.46 

76.45 

Jireh diabetic flour. 

14.30 

2.21 

71.95 

Special diabetic flour. 

Gluten flour. 

14.25 

13.30 

2.96 

1.05 

67.47 

72.11 

Gluten flour. 

16.40 

3.15 

70.60 


the muscle fibers. While heat coagulates the albumins of meat, and, it is 
thought, renders them slightly less digestible; this effect is probably more 
than offset by the above-mentioned advantages, unless the meat be cooked 


Vegetables consist for the most part of starch, which is inclosed within 
cellulose walls. Cellulose is practically undigested by man, and much of 
the starch of raw vegetables escapes from the body in the feces. More¬ 
over, raw starch itself is difficult of digestion. During the process of cook¬ 
ing, the starch grains swell, burst the cell walls, and become softer. In 
addition starch is converted partly to dextrin; this occurs both in moist 


and dry heat. 










































106 


NUTRITION AND DIETETICS 


Except for the development of flavor, fats are probably affected but 
little by the process of cooking unless they are scorched. 

3 . To destroy parasites and bacteria. 

When meat is taken only from healthy animals and is properly in¬ 
spected, there is little danger from parasites or bacteria. But these pre¬ 
cautions are not always followed, especially in the case of meats which are 
sold to the poor; therefore, meats of doubtful origin should always be 
thoroughly cooked. 

Vegetable foods, likewise, may carry infection. The typhoid bacillus, 
for example, may enter the body upon green vegetables which have been 
washed or grown in polluted water. 

Cooking Meats.—The various methods of cooking meats may be 
grouped under two headings: 

1 . Methods which are intended to prevent the loss of the juices of 
the meat, such as roasting and broiling. By these methods the meat is 
heated rapidly, the surface albumin coagulated, and the juices of the meat 
retained. 

2 . Methods which permit the loss of the juices, such as boiling and 
stewing. With these methods the meat is heated slowly, and the juices 
escape to a greater or lesser extent. 

Losses in Cooking Meat .—Meat loses in weight whatever the method 
of cooking. This is due to the driving off of water, and it follows that a 
given weight of cooked meat holds a higher percentage of nutriment than 
the same weight of raw meat. According to Grindley, the loss in weight 
amounts to one-fifth to one-third, whether the meat be boiled or roasted. 
The loss in the solids of the meat is greatest when it is boiled or stewed, 
and the longer it is cooked the greater the loss. The loss may reach from 
3 to 20 per cent. 

While meat which is boiled gives up most of its flavor to the water and 
becomes insipid, it loses very little of its nutriment. It is the rich taste 
of beef tea which gave rise to the fallacy that it contained the nutritious 
elements of the meat in quantity. 

Cooking Vegetables and Losses Incurred.—Losses occur in the cook¬ 
ing of vegetables, which are comparable to, but perhaps not so important 
as, those which occur in the cooking of meats by methods which do not 
retain the juices. The losses in the cooking of vegetables depend largely 
upon the method employed, and concern chiefly the sugars and salts which 
are soluble in water, though nitrogen also is lost. The losses to which 
potatoes, carrots, and cabbage, selected as types, are subject have been 
studied by Snyder. His experiments showed the following results: 

1 . That in order to obtain the highest food value, potatoes should 
not be peeled before cooking. 

2. When peeled, the least loss occurs if the potatoes are put directly 
into boiling water, though the loss is still considerable. 


THE EFFECTS OF COOKING UPON FOOD 


107 


3. When peeled and soaked in cold water before cooking, the loss 
may reach one-fourth of the protein matter. 

Similar losses may occur in the cooking of carrots and cabbage. 

Breadmaking. —Snyder and Voorhees investigated the losses of flour 
in breadmaking. They affect both the nitrogen and carbohydrate. The 
loss in nitrogen may reach 1.45 per cent. The carbohydrate loss is caused 
by the fermentation which the bread undergoes in “rising” (yeast cells). 
The authors state that the losses in breadmaking need not exceed 2 per 
cent of the flour used, and may be reduced to 1.1 per cent. 

Cereal Breakfast-Foods.—The importance of cereal breakfast-foods 
has been shown especially by the investigations of Woods and Snyder. 
These authors found that cereals comprise 22 per cent of the total food of 
a large number of families in this country, furnishing 31 per cent of the 
protein, 7 per cent of the fat, and 55 per cent of the total carbohydrates. 
They have separated the large number of cereal breakfast-foods which 
are on the market into three groups: 

1. Those prepared simply by grinding the grain. 

2. Those which have been steamed, or otherwise partially cooked, and 
then ground or rolled. 

3. Those which have been acted upon by malt which induces chemical 
changes in the starch. 

Cooking Cereals .—The proper cooking of cereals is of more impor¬ 
tance than the relative proportions of nutriment they contain. While 
definite statements cannot be made regarding the length of time which 
different cereals should be boiled, all of them require prolonged cooking. 
They are much more likely to be undercooked than overcooked. With 
undercooked foods starch grains may appear in the feces, due to the cover¬ 
ings of the granules which are impermeable to the digestive juices. In 
general, the more abundant and the tougher the. fiber the longer should the 
process of cooking be continued. For example, whole grains require more 
cooking than crushed grains. Rice contains but little fiber and may be 
thoroughly cooked in a relatively short time. 

According to Woods and Snyder, it is difficult to know in the case 
of partially cooked breakfast-foods how much of the necessary cooking 
has been done in the factory. They point out that overcooking is harm¬ 
less, and suggest that further cooking in the home is usually desirable. 

Examinations of malted breakfast cereals carried out at the Iowa 
Experiment Station showed that the largest amount of soluble carbo¬ 
hydrate present was 13 per cent of the total carbohydrates, the lowest, 0.35 
per cent. The average was around 5 per cent. At the Michigan Station 
it was found that the largest proportion of the soluble carbohydrates in 
these preparations consists of dextrin. Woods and Snyder state that “the 
claims made for some brands that the carbohydrates are completely or 
largely predigested are quite unwarranted.” 


108 


NUTRITION AND DIETETICS 


DIGESTIBILITY OF FOODS 8 

General Considerations. —The term “digestibility” may be under¬ 
stood to mean either the ease and rapidity with which a food is digested, 
or the completeness of its digestion. This distinction is not always made, 
however, and confusion has often arisen in the interpretation of the 
results obtained by different observers. Likewise, when the opinions of 
physicians and physiologists are not in agreement, the fact is often over¬ 
looked that the conditions under which the observations are made are 
different. Physicians deal with those who are ill, physiologists with 
those who are well. The term “digestibility” is probably understood by 
most physicians to mean ease of digestion, by most physiologists com¬ 
pleteness of digestion. If these different points of view are borne in 
mind, discordant opinions may frequently be reconciled. 

Foods leave the stomach in the order in which they are digested and 
liquefied. The length of time they remain in the stomach has been 
taken by some authors as the measure of their digestibility. While the 
length of its sojourn in the stomach may not affect the thoroughness with 
which a food is ultimately digested, it may have an important influence 
upon subsequent feedings, especially if these be given at short intervals. 
Delay in gastric digestion often produces in healthy persons unusual or 
uncomfortable sensations referable to the stomach. In persons who are 
ill, delay of gastric digestion may not only interfere with the frequency 
of the feedings, but may cause loss of appetite, nausea, and even the 
rejection of food. 

The nutritive values of foods cannot always be measured by the 
amounts of the different foodstuffs they contain. They depend rather 
upon the extent to which these foodstuffs may be digested and absorbed. 
While it is generally believed that the greater part of most foods is 
digested and absorbed by healthy men, our knowledge of the extent to 
which they are utilized by persons who are ill is far from complete. 

A number of factors affect the digestion and utilization of foods. 
Some of the more important of them may be considered. 

The favorable influence of appetite upon digestion has been known 
so long that it is best expressed in the form of the adage, “Hunger is 
the best sauce.” It was only about twenty years ago, however, that Pavlov 
established the popular belief upon a scientific basis through his dis¬ 
covery that the desire for food induces a reflex stimulation of gastric 
juice. Pavlov calls this secretion the “appetite” or “igniting juice.” Its 
function is to initiate the digestive process, which then proceeds more 
or less automatically through the stimulating action of the products of 

8 In the preparation of this section the author has derived much information from 
U. S. Dept, of Agriculture Bull. No. 85, and Farmers’ Bulls. Nos. 85. 121, 128, 182. 



DIGESTIBILITY OF FOODS 


109 


digestion upon the gastric glands. Food eaten without appetite may lie 
in the stomach unchanged for hours. Physicians have made use of this 
knowledge for many years, and have striven to arouse an appetite in 
patients when it was lacking. Another, and related, adage, “Laugh and 
grow fat,” finds application here. Meals eaten amid cheerful surround¬ 
ings and in pleasant company are taken with greater zest and enjoyment, 
and are more easily digested. 

The ease and completeness of digestion also depend in general upon 
the amount of food which is eaten at a time; the greater the quantity 
the less rapidly, and probably less thoroughly, is it digested. Overeating 
is a common cause of digestive disorders. The custom of taking three 
meals a day is based upon the general experience of mankind that the 
amount of food required can be handled with less tax upon the digestive 
organs when distributed in this manner. 

Careful regulation of the quantity of food allowed at one time is of 
even more importance when persons are ill or have “weak” digestions. 
The common practice of giving small quantities of food at frequent inter¬ 
vals to persons with enfeebled powers of digestion is supported by the 
experiments of Pavlov, who found that if food was given to a dog in 
small quantities at intervals, the gastric juice was stronger than if the 
whole ration had been given at once. Moreover, the appetite of an 
invalid is often impaired by even the sight of large “portions” of food. 

Experiments upon healthy men have repeatedly shown that a well- 
balanced dietary is digested more thoroughly than a single food. The 
significance of such observations, with respect to the arrangement of 
dietaries for invalids, is apparent. 

The secretion of gastric juice is intimately related to the quantity of 
water in the body (Pavlov). Water is drawn from the blood by the 
cells of the gastric glands as they elaborate the secretion. If the supply 
of water is not sufficient, the digestive juices are deficient in quantity, 
and digestion is impaired. Therefore, water should he supplied to the 
body by enemata or otherwise, as an aid to digestion, in diseases attended 
by its loss in large quantities, such as excessive vomiting, profuse diar¬ 
rhea, and hemorrhages. “Every food determines a certain amount of 
digestive work, and when a given dietary is long-continued, definite, and 
fixed, types of gland activity are set up which can he altered hut slowly 
and with difficulty. In consequence, digestive disturbances are often 
instituted, if a change he made suddenly from one dietary regime to 
another, especially from a sparse to a rich diet” (Pavlov). It should be 
added that patients cannot all be fed alike, even when suffering from 
the same disease. Prejudices and idiosyncrasies to foods are not re¬ 
moved by illness, and must be recognized. Variety in food is sought in 
health and should he permitted in disease to the extent which is com¬ 
patible with the patient’s well-being. 


110 


NUTRITION AND DIETETICS 


Digestibility of Meats.—Numerous observations concerning the di¬ 
gestibility of meats have been made upon healthy men. Valuable data 
have also been obtained by Pavlov and his coworkers from their experi¬ 
ments upon dogs. But we possess very little information respecting the 
digestibility of meats in various diseases. The conclusions drawn from 
experiments upon healthy men refer particularly to the thoroughness of 
digestion. They should not be applied without caution to persons who 
are ill, and who, on that account, may digest meat slowly and with 
difficulty. 

Probably the most important conditions affecting both the rate and 
completeness of digestion of meat are the amount of connective tissue and 
fat it contains, and the method and duration of the cooking. 

The “appetite” juice plays a less important role in the digestion of 
meat than in the digestion of eggs and bread. This is due to the presence 
of extractives in meat, which are direct excitants of the gastric glands. 
According to Pavlov, the secretion of “meat juice” is the most rapid of 
all. Raw meat, introduced unnoticed into the stomach of a dog, excites 
secretion within from 15 to 30 minutes. But if meat be freed from extrac¬ 
tives by prolonged boiling, and the water be forced from it by compres¬ 
sion, it has no stimulating effect upon the gastric glands. 

The influence of the connective tissue upon the digestion of meat is 
mainly mechanical, though the mastication of tough, fibrous meat is not 
attended with pleasure. The presence of much connective tissue prevents 
free access of the digestive juices to the muscle fiber, and affects both 
the rapidity and completeness of digestion. The practice of pounding 
meat across the cut ends has for its object the separation of the muscle 
fibers from the connective tissue. Likewise, the prolonged cooking of 
meat converts the connective tissue into gelatin, and frees the muscle 
fibers, though they are probably rendered slightly less digestible by the 
process. 

Influence of Fat-Content Digestion of Meat .—Meats vary in the 
amount of fat they contain. Dried meat may not have more than 3 per 
cent of fat, while pork may contain as much as 50 per cent. The pres¬ 
ence of fat inhibits the secretion of gastric juice, and prolongs the stay 
of both protein and carbohydrate in the stomach. Therefore, the rapidity 
of the digestion of meat bears a direct relation to the amount of fat it 
contains. Eat meats, such as pork, are well known to be difficult of 
digestion. 

While but little attention has been devoted to the percentages of the 
different meats which are absorbed, it is probable that meat of all kinds, 
whether raw or cooked, is very completely absorbed by healthy men— 
nearly all of the protein and about 95 per cent of the fat. 

Our knowledge of the digestibility of meat in disease is confined 
largely to the results of clinical observation. While carefully made ob- 


DIGESTIBILITY OF FOODS 


111 


servations of this kind have a definite value, it is desirable that they should 
be confirmed by experiment. Yet, one of the conspicuous features of Pav¬ 
lov’s work is the frequency with which he has confirmed both popular 
and clinical beliefs respecting digestion. 

In giving meat to invalids, every precaution should he taken which . 
will make for rapidity of digestion. It should he served attractively 
and in not too large “portions” in order to promote the secretion of the 
“appetite” juice. If given raw, it should be finely scraped, as this sep¬ 
arates the fibers from the connective tissue. Paw meat should not be 
forced upon a patient, since it is not certain that raw meat is more 
quickly digested than slightly cooked meat. If cooked too long, the, 
muscle fibers become hard, tasteless to many persons, and difficult to 
digest. Furthermore, meats which contain relatively little fat should 
be selected for invalids. 

Poultry is popularly supposed to be more easily digested than red 
meats. As no experiments contradict this belief, it may provisionally be 
accepted. If true, it is probably due to the tenderness of the fiber and 
the relatively small proportion of fat. The fatter kinds of poultry are 
less easily digested than the lean. The popular belief that the light meat 
is more digestible than the dark may be due to the higher proportion of 
fat in the dark meat, hut the difference is slight. 

Attention should be directed here to the fact that the extractive-con¬ 
tent is essentially the same in white and red meats. In diseases where 
it is desirable to reduce the purin bodies to a minimum there is no advan¬ 
tage in prohibiting red meats, if the patient is allowed to eat poultry 
at will. It is probably true, so far as the sick are concerned, that the 
only difference between white and red meats concerns ease of digestion. 

Digestibility of Fish. —The relative digestibility of different fish ap¬ 
pears to be dependent upon the amount of fat they contain. Langworthy 
has grouped the commoner fish, from this standpoint, into three classes: 

1. Fish containing over 5 per cent of fat: salmon, shad, herring, 
Spanish mackerel, and butterfish. 

2. Fish containing between 2 per cent and 5 per cent of fat: white- 
fish, mackerel, mullet, halibut, and porgy. 

3. Fish containing less than 2 per cent of fat: smelt, black bass, blue- 
fish, white perch, weakfish, brook-trout, hake, flounder, yellow perch, pike, 
pickerel, sea bass, cod, haddock. 

Digestibility of Eggs. —Most of the experiments upon the digestibility 
of eggs have been made upon healthy men and lower animals. All of 
them indicate that eggs are easily and thoroughly digested. Buhner found 
that with a diet consisting of hard-boiled eggs alone the nitrogen was 
absorbed to about the same extent as that of meat, while the fat was 
absorbed better than the fat of meat. Aufrecht and Simon studied the 
absorption of lightly boiled and raw eggs, compared with meat, as part 


112 


NUTRITION AND DIETETICS 


of a mixed diet, and found that the absorption of both the nitrogen and 
fat was greater in the egg—than in the meat—period. They concluded 
that lightly boiled and raw eggs have a higher food value as part of a 
mixed diet than a corresponding amount of meat. 

The method of cooking eggs appears to affect the rate rather than the 
completeness of their digestion. While this has no appreciable effect in 
health, it may cause disorders of digestion in disease. Judged by the 
length of time they remain in the stomach, eggs are digested in the fol¬ 
lowing order (the most easily digested are given first) : lightly cooked 
eggs, raw eggs, buttered eggs, hard-boiled eggs, omelette. Judged by the 
completeness of absorption, Aufrecht and Simon have shown that lightly 
boiled eggs have a somewhat lower nutritive value than raw eggs. Joris- 
senne believes that if hard-boiled eggs are thoroughly masticated they are 
digested as easily as lightly cooked eggs. Very few experiments have been 
made upon the relative digestibility of the white and the yolk of the egg. 
Stern found that raw or half-raw yolk is readily digested, and Rose 
and Macleod have found that there is very little difference in the di¬ 
gestibility of raw or cooked whites of eggs. 

While it is probable that the facts regarding the digestibility of eggs 
by healthy men apply equally to those who are ill, positive statements to 
this effect cannot be made. Probably the most important factor influ¬ 
encing the digestibility of eggs in disease is whether they are taken with 
relish. White of egg eaten without appetite will lie in the stomach un¬ 
changed for a considerable time (Pavlov). This is due to the fact that 
the egg contains no substances like the extractives of meat which are 
capable of exciting the flow of gastric juice. Once the flow is started, 
the products of digestion stimulate further secretion. If water he taken 
with egg-albumin it initiates the secretion (Pavlov). A similar result 
is obtained if the egg is preceded by, or given with, meat broth. The 
difference in digestibility between lightly cooked and raw eggs is so slight 
that it is not necessary to compel patients to take them raw. When a 
patient’s digestive powers are much enfeebled, eggs should not he but¬ 
tered, hut there is no objection to the addition of salt and pepper. Eraser 
found in experiments upon the artificial digestion of eggs that tea, coffee, 
and cocoa retarded digestion of the protein, though the effect of coffee 
was less marked than that of the others. 

Idiosyncrasy to Eggs .—Persons are seen occasionally who have an 
idiosyncrasy against eggs. The peculiarity is usually discovered early in 
life. The symptoms develop after eating egg even in small quantities 
and irrespective of whether it is taken alone or combined with other foods, 
as in custards. The symptoms are often severe; collapse may occur. 
Urticaria is common. 

The Digestibility of Milk.— The following account of the digestibility 
of milk is taken principally from Pavlov. There are three properties of 


113 


DIGESTIBILITY OF FOODS 

milk which secure it an exceptional position. Milk, when compared with 
other foods in nitrogen equivalents, requires the weakest gastric juice and 
the smallest quantity of pancreatic fluid. Consequently, the secretory 
activity necessary for its assimilation is much less than for any other food. 
When milk is introduced mechanically into the stomach of an animal, it 
causes a secretion both from the stomach glands and also from the pan¬ 
creas, consequently it appears to be an independent chemical excitant 
of the digestive canal, and in this action there is no essential difference 
whether the milk he introduced directly into the stomach or he given the 
animal to lap. Milk excites not only a really effective, hut also a very 
economic secretion, and the appetite is unable to stimulate this secretion 
into a more active or abundant flow. The price which the organism pays 
in digestive work for the nitrogen of milk is much less than for other 
foods. 

Idiosyncrasy to Milk .—In rare instances persons exhibit an idiosyn¬ 
crasy against milk. Halberstadt considers this to he evidence of a con¬ 
genital constitutional anomaly. The idiosyncrasy may be against the al¬ 
bumin, fat, or whey. In some cases the deleterious effects of milk are 
thought to be due to a change it causes in the flora of the intestine. Defi¬ 
nite poisoning occurs in these cases, often accompanied by inflammatory 
changes in the alimentary tract, and must be differentiated from the diges¬ 
tive disturbances, which, many physicians claim, are always caused by 
milk. Tugendreich has described a similar poisoning under the title of 
“Buttermilk Fever.” 

Digestibility of the Carbohydrates. —The digestibility of the carbo¬ 
hydrates depends in general upon the relative proportions of starch (or 
sugar) and cellulose. The greater the amount of cellulose and the thicker 
the cell walls the less digestible is the food. The preparation of certain 
foods, such as the milling of grain, has for its object the removal of the 
greater portion of the cellulose. Sugars may be regarded as partially 
digested carbohydrates. Except when taken in quantities, and in mix¬ 
tures, which interfere with the normal processes, they are easily digested 
and completely absorbed. Carbohydrates leave the stomach quickly. 

Bread and cereals may be taken as types of the carbohydrate foods. 

Digestibility of Bread .—Bread is generally considered to be an easily 
digested food, but the “appetite” juice is necessary for its perfect diges¬ 
tion. Bread eaten without appetite may lie in the stomach for a long 
time without change. Bread is digested chiefly by the pancreatic secre¬ 
tion. The lactic acid which is formed in the stomach stimulates the 
pancreas and thus aids the digestion. 

The majority of the experiments on the digestibility of bread relate 
to the completeness of its digestion by healthy men. Myer and Yoit, ex¬ 
perimenting with different kinds of wheat and rye bread, found that the 
digestibility of bread depended chiefly upon its lightness. Studies car- 


114 


NUTBITION AND DIETETICS 


ried out at the Minnesota Experiment Station upon the digestibility of 
breads made from graham, whole wheat, and standard patent flours dem¬ 
onstrated that bread made from standard patent flour was most com¬ 
pletely digested, whole wheat bread next, and graham least. The digesti¬ 
bility of crackers, macaroni, and various sweet cakes made from white 
flour was found at the same Station to be essentially the same as that of 
bread. 

There is a popular belief that cold bread is more easily digested than 
hot bread. This is probably true but it is due to the physical condition 
of the bread and not to the heat. Hot bread is moist, and, if not soggy 
before being eaten, is compressed into tough masses during mastication, 
and thereby rendered less easily digestible. If properly made, cold or 
stale bread contains less moisture and is not open to the same objection in 
that it does not form these tough masses, during mastication. 

As far as is known the above facts are applicable in disease. Du Bois 
found that bread and crackers are easily and completely digested by 
typhoid fever patients. 

When bread and similar foods are eaten by persons who have little or 
no appetite, they should he combined with substances which have a local 
stimulating action upon the gastric glands. Water is sufficient for the 
purpose, but meat broth is often to be preferred. 

Digestibility of Cereal Breakfast Foods .—The digestibility of cereal 
breakfast foods has been investigated at the Connecticut, Maine, and Min¬ 
nesota Experiment Stations. The results showed that in healthy men the 
cereal breakfast foods in general are somewhat less digestible than white 
bread. It was found at the Michigan Experiment Station that the greater 
part of the soluble carbohydrates in the so-called predigested breakfast 
foods consists of dextrin. 

Digestibility of Fat. —Fat illustrates especially well the distinction 
which must be made between ease and completeness of digestion. All 
healthy persons consume daily larger or smaller quantities of fat in the 
form of butter, cream, or the native fats contained in other foods. But 
an excess of fat over the usual quantity or a change in its form is dis¬ 
tasteful to many persons, difficult to digest (as regards the stomach diges¬ 
tion), and may produce nausea. Nevertheless, if it is tolerated by the 
stomach, only a small portion of the fat ingested escapes absorption in 
health. 

Eat is not digested in the stomach, but may have an important in¬ 
fluence on gastric digestion. Eat exerts an inhibitory action upon both 
the psychic or “appetite” and local gastric juices, and delays the pas¬ 
sage of the chyme into the duodenum (Pavlov). The inhibitory action of 
fat affects especially the digestion of protein, and explains the well-known 
fact that fatty protein foods are difficult to digest, whether the fat be 
native to the food or be added to it in the process of cooking. On the 


DIGESTIBILITY OF FOODS 


115 


other hand, the addition of fat to starchy foods, for example, bread and 
butter, is customary, and, according to Pavlov, rational. Bread requires 
little gastric juice for its digestion; the fat restrains the activity of the 
gastric glands, while at the same time it promotes the secretion of pan¬ 
creatic juice, which is needed for the digestion of the starch, the partially 
digested protein, and the fat itself. Though an excess of fat in a mixed 
meal may cause disturbances of digestion, fat alone, even when taken in 
relatively large quantities, is not difficult to digest. 

Large amounts of fat may cause regurgitation of the duodenal con¬ 
tents into the stomach. This fact has been observed both experimentally 
and clinically (Bassler). 

Ordinarily, fat is well absorbed in health. Its absorption appears to 
bo related in a measure to its melting-point. Butter, with a melting-point 
of 37° C., is more completely absorbed than mutton-fat, with a melting- 
point of 52° C. When the food contains 80 to 100 grams of fat, only 
4 to 6 per cent is lost normally in the feces. 

The absorption of fat varies greatly, however, in disease. According 
to Umber, 45 per cent of ingested fat may be lost in the feces when the 
bile duct is occluded. Thus in obstructive jaundice fat absorption may be 
interfered with. In disease of the pancreas the loss may reach 75 per 
cent. On the other hand, the absorption of fat in typhoid fever is often 
remarkable. Some of my patients, studied by Du Bois, when taking 
250 grams of fat a day in the form of cream and butter, lost an average 
of 7.2 per cent in the feces; in the steep-curved period and in con¬ 
valescence, while taking similar amounts, they lost 4.5 per cent. 

Length of Time Food Remains in Stomach. —The length of time 
which a food remains in the stomach has often been accepted as the meas¬ 
ure of its digestibility, but is probably only an indication of the ease of 
its digestion. 

The length of time which certain foods remain in the stomach is 
shown in the following table of experiments by Penzoldt: 

One to Two Hours 


Grams 


Kind of Food 


100-220 

220 

200 

200 

200 

200 

200 

100-200 

200 

200 

100 


.Water 

. “Charged” water 

1 Without 

"n° 66 I admixture 
. Cocoa J 

. Beer 

.Light wine 
.Boiled milk 
.Meat broth 
.Peptone in water 
.Soft-boiled egg 













116 


NUTRITION AND DIETETICS 


Two to Three Hours 

Grams Kind of Food 

200 Coffee with cream 

200 Cocoa with milk 

200 .Malaga wine 

300-500 .. ..Water 

300-500 .Beer 

300-500 Boiled milk 

100 .Raw, scrambled, hard-boiled 

egg and omelette 

250 Calf’s brain, boiled 

12 .Raw oysters 

200 Boiled carp 

200 Boiled pike 

200 Boiled haddock 

200 Dried codfish 

150 Boiled cauliflower 

150 .Cauliflower salad 

150 .Boiled asparagus 

150 Potato 

150 .Potato soup 

150 .Cherry preserves 

150 .Raw cherries 

70 .'White bread, fresh or old, 

dry or with tea 

70 .Cracknel 

50 .Albert biscuits 

Three to Four Hours 

230 Boiled young fowl 

230 .Roast partridge 

220-260 .Boiled pigeon 

195 .Roast partridge 

250 .Beef, raw or cooked 

250 Boiled calf’s foot 

160 .Ham, raw or cooked 

100 ..Roast veal, warm or cold 

100 .Broiled beefsteak, cold or 

warm 

100 .Scraped raw beefsteak 

100 ..Tenderloin 

200 .Rheinsalmon, boiled 

72 .Caviar 

150 .Rye bread 

150 .Graham bread 

100-150 .Albert biscuit 

150 .Boiled rice 

150 .Boiled cabbage 

150 .Boiled carrot 

150 .Spinach 

150 .Raw radish 

150 .Apple 















































EFFECTS OF STARVATION 


117 


Four to Five Hours 


Grams Kind of Food 

210 .Roast pigeon 

250 .Broiled filet of beef 

250 .Broiled steak 

250 .Smoked tongue 

100 .Smoked meat 

250 .Roast hare 

240 .Roast partridge 

250 .Roast goose 

250 .Roast duck 

200 .Salt herring 

150 .Lentil soup 

200 .Pea soup 


Coefficients of Digestibility (Absorbability) in Different Groups of Food 

Materials * 


Kind of Food 

Per Cent 
Protein 

Per Cent 

Fat 

Per Cent 
Carbo¬ 
hydrates 

Meats and fish. 

97.0 

95.0 

.... 

Eggs. 

97.0 

95.0 

.... 

Dairy products. 

97.0 

95.0 

98.0 

Animal food (of mixed diet). 

97.0 

95.0 

98.0 

Cereals . 

85.0 

90.0 

98.0 

Legumes (dried). 

78.0 

90.0 

97.0 

Sugars. 

.... 


98.0 

Starches . 

.... 

.... 

98.0 

Vegetables . 

83.0 

90.0 

95.0 

Fruits . 

85.0 

90.0 

90.0 

Vegetable foods (of mixed diet). 

84.0 

90.0 

97.0 

Total food (of mixed diet)... 

92.0 

95.0 

97.0 


* From U. S. Dept, of Agriculture Farmers’ Bull. No. 142. 


EFFECTS OF STARVATION 

It will be necessary to distinguish between the effects of complete and 
of partial deprivation of food. Starvation is complete when a person 
receives no food and the energy necessary for the continuance of life is 
derived from his own body. Partial starvation occurs when a person 
receives only a portion of the food he requires. Under such circumstances 
the tissues of the body are drawn upon for only part of the necessary 
energy. In actual practice, however, the physician must take into con¬ 
sideration the possible disturbances of metabolism produced by the disease 
from which the patient is suffering, and which also may be a cause of 
the starvation. 

Effects of Complete Starvation.—Complete abstinence from food for 
short periods is not—or, at least, is not likely to be—harmful in the case 
of adults. Nature provides for such emergencies by accumulating reserves 

































118 


NUTRITION AND DIETETICS 


of glycogen and fat. Young children, on the other hand, do not bear 
starvation well, even for short periods. The reserve supply of glycogen 
is relatively small, and is soon exhausted. After its exhaustion, the body 
derives all of its energy from protein and fat. Eat, which is of lesser 
importance, is sacrificed in favor of protein. The heavy demand made 
upon the fat results in its incomplete combustion and the occurrence of 
acidosis with acetone bodies in the blood and urine. 

The expenditure of energy by the body remains normal for the first 
day or two of complete starvation. Rubner reckons it at from 30 to 32 
calories per kilogram of body weight. When the subject is at absolute 
rest, however, the heat production may fall to 22 to 26 calories per 
kilogram (Atwater, Tigerstedt, Magnus-Levy). These figures represent 
the minimal metabolism compatible with life, and cannot be applied in 
practice, because patients are rarely or never at complete rest, unless they 
are asleep or in coma. 

Loss of weight is characteristic of starvation. It is due to the con¬ 
sumption of the body tissues and to the elimination of water and salts. 
As the weight diminishes, the expenditure of energy falls, the fall, accord¬ 
ing to Rubner, corresponding to the loss in weight. The body tempera¬ 
ture remains practically constant. The urine is diminished in amount. 
The loss of nitrogen is large for the first day or so, after which it re¬ 
mains fairly constant (10 to 13 grams) for a week or ten days. Material 
divergence from these figures indicates the influence of disease. However, 
in long fasts factors other than the simple sparing of the direct effect of 
food come into play. 

Benedict has shown that recovery from starvation is rapid in health 
and may be followed by an actual gain in weight. Fasting for short 
periods appears to stimulate the body to increase its store of fat. This 
is regarded by Benedict to be a protective mechanism. 

Effects of Partial Starvation. —Partial starvation may occur through 
force of circumstances, such as poverty, or as the result of disease. In 
the latter case it is not always easy to distinguish between the influence 
of insufficient food and that of the disease. From the medical standpoint 
partial starvation probably occurs with greatest frequency in prolonged 
febrile and in malignant diseases. 

The body is capable of regulating its expenditure of energy to some 
extent. When the food supply is insufficient the production of energy falls 
correspondingly. But von Noorden believes that the minimal amount 
of energy required by persons who are bedridden, or who remain indoors 
and do but little work amounts to from 30 to 32 calories per kilogram. 
Their diets should be arranged upon this basis. Persons who are under¬ 
fed economize their protein at the expense of the less important fat. The 
longer the deprivation of food continues the smaller the relative amount 
of protein consumed. 


EFFECTS OF OVERFEEDING 


119 


It should be added that persons who are undernourished are less able 
to resist invasion by bacteria and to combat infection. 


EFFECTS OF OVERFEEDING 

A person is overfed when he takes and absorbs more food than is 
required for his energy exchanges. If an excess of food is not digested 
and absorbed, it is likely to cause alimentary disturbances. 

The effects of overfeeding may be either physiological or pathological, 
that is, the general condition of the person may be improved, or various 
disturbances of function may be brought about. We are concerned here 
chiefly with the physiological effects of overfeeding. 

A person who is overfed gains in weight, largely through the deposi¬ 
tion of fat, though there may be a coincident retention of nitrogen. Fat 
is a relatively inactive tissue from the metabolic standpoint. The accumu¬ 
lation of fat adds to the reserves, but does not increase the power of the 
body. Improvement in tone, if not growth, of muscle is necessary to 
bring the body into a state of vigorous health. This depends to a great 
extent upon proper exercise, and should be borne in mind when one is 
employing the overfeeding cure. 

The objects to be sought in overfeeding may be either the accumula¬ 
tion of fat, or improvement in the condition of the muscles, or both. In 
arranging the diet the effects of the different foodstuffs must be taken 
into consideration. Fat is the best food for simple fattening purposes, 
because foreign fats are deposited in the body without change and with 
the expenditure of very little energy. Carbohydrate ranks next to fat in 
value. It has been estimated that one-fourth of the potential energy of 
carbohydrate is lost before it is deposited as fat. Protein is least valuable 
because of the increase it causes in metabolism and because it cannot add 
materially to the store of fat. Therefore, an increase in protein alone is 
irrational in overfeeding cures. Van Noorden advises specifically against 
the employment of proprietary protein foods for such purposes. Even 
in convalescence from infective diseases an increase of protein does not 
materially affect the retention of nitrogen. 

While the experiments of both Krug and Dapper indicate that an 
increase in the carbohydrate ration and a relatively greater increase of 
fat are accompanied by a retention of nitrogen in lower animals, this 
fact has not yet been established for man except in typhoid fever. Typhoid 
fever patients may retain nitrogen during the course of the disease and 
in convalescence when the diet furnishes an excess of both carbohydrate 
and fat (Shaffer and Coleman). 

General clinical experience appears to indicate that the most suitable 
diet for an overfeeding cure is rich in both fat and carbohydrate. The 


120 


NUTRITION AND DIETETICS 


Yoit or Atwater standard should be followed in determining the amount 
of protein. In all cases the total energy requirement of the patient should 
be calculated and the diet arranged to furnish more energy than the cal¬ 
culation calls for. 

While the pathological effects of overfeeding cannot be considered at 
length, attention should he called to the fact that injudicious overfeeding 
may cause pathological obesity. 


METHODS OF ARTIFICIAL FEEDING 

When for any reason patients cannot or will not take food by mouth, 
other methods of nourishing them must be employed. 

Rectal Feeding. —Rectal feeding may be resorted to when swallow¬ 
ing is difficult or impossible as in cases of tumor or stricture of the throat 
or esophagus; when the muscles of deglutition are paralyzed; in cases of 
ulcer or tumor of the stomach; and in cases of uncontrollable vomiting. 
When for any reason patients are incapable of taking all the food they 
require by mouth, additional food may he given for brief periods per 
rectum. 

The nutritive value of nutrient enemata has, according to recent in¬ 
vestigations, been greatly overestimated, and the physician should keep 
clearly in mind the fact, when employing this method of alimentation, 
that the patient is receiving only a portion of the food he requires. Pa¬ 
tients have subsisted upon nutrient enemata for several weeks, hut it has 
been largely at the expense of the body tissues. The gains in weight 
which have occurred, especially after severe hemorrhages, have been shown 
to he due to retention of water. Probably the greatest quantity of food 
which a patient is capable of absorbing by rectum reaches only from one- 
fourth to one-third of the total daily requirement, even when at rest in bed. 
Boyd calls attention particularly to the fact that the amount of food ab¬ 
sorbed depends upon the patient’s capacity for absorption, and not upon the 
quantity of food injected. Therefore, it is not always desirable to give 
large enemata; the unused portion is likely to decompose and cause 
irritation. 

Nutrient enemata do not enter the ileum, and such absorption as occurs 
must he from the colon. Nor do nutrient enemata cause a reflex secretion 
of gastric juice (Pavlov). 

The different foodstuffs are not absorbed with equal facility by the 
colon. All of the available evidence indicates that protein is poorly 
absorbed. Brown compared the nitrogen output in the urine from saline 
and nutrient enemata, and observed not only that the curves were similar, 
but that they were comparable to the nitrogen excretion of healthy fasting 
men. When the same amount of food was given by mouth the nitrogen 


METHODS OF ARTIFICIAL FEEDING 121 

of the urine rose at once. Therefore, since hut little protein is absorbed, 
and since proteins are readily decomposed by the intestinal flora, giving 
rise to substances which may irritate the bowel, it appears to he undesir¬ 
able to give nutrient enemata containing protein even in its partially 
digested forms. 

There is a difference of opinion regarding the absorption of fat. 
Brown was unable to prove the absorption of emulsified and pancreatized 
fats when given by rectum to a patient suffering from chyluria, though 
when fat was taken by mouth the amount in the urine was promptly in¬ 
creased. Boyd, on the other hand, has shown that fat may be absorbed, 
though he calls attention to the wide differences in the absorptive power 
of different individuals. Boyd recommends yolk of egg and emulsified 
olive oil as suitable fats for nutrient enemata. Cream has also been 
used. 

Dextrose is readily absorbed by the large intestine, and is probably 
the best form in which to give carbohydrate. Dextrin has also been 
recommended. Brugsch states that dextrinized or malted starch is less 
irritating than the sugars, and may be employed instead of them. Brown 
was able to raise the respiratory quotient by the use of dextrose and to 
cause the diminution or disappearance of acidosis. Dextrose may irritate 
the bowel and cause cramplike pains when given in concentration greater 
than 10 per cent. I have found it necessary at times to reduce the strength 
of the solution to 7 per cent and even to 5 per cent. If sugar is ab¬ 
sorbed by the inferior hemorrhoidal veins, it enters the general circula¬ 
tion without passing through the liver, and may cause glycosuria. 

Salts and water are readily absorbed by the colon, and there is little 
doubt that much of the benefit which has been ascribed to nutrient 
enemata was attributable to these substances. Alcohol, likewise, is readily 
absorbed, and is often added in small quantities to enemata. 

Method of Giving Nutrient Enemata .—A cleansing enema of normal 
salt solution (0.9 per cent) should he given every morning one hour before 
the nutrient enema. Some authors recommend a cleansing enema before 
each nutrient enema, but unless the nutrient enema contains foods which 
are not readily absorbed this procedure scarcely seems necessary, and may 
increase the irritability of the colon. The patient should he placed either 
upon the left side or the hack with the hips elevated on a pillow. The 
apparatus may consist of a medium-size funnel inserted into the end of a 
small rectal tube or large catheter, or an inverted thermos bottle con¬ 
nected with the rectal tube or catheter by means of rubber tubing. A 
small metal tube passed through the stopper and reaching to the bottom 
of the bottle permits the entrance of air and the flow of its contents. A 
bulb-syringe is not suitable because of the difficulty of controlling the pres¬ 
sure, and the likelihood of injecting air. The funnel-apparatus is per¬ 
haps more convenient for thicker enemata; the bottle, for the sugar solu- 


122 


NUTRITION AND DIETETICS 


Formulae for Nutrient Enemata 


Nutrient 

Weight 

Calories 

Dextrose. 

20- 30 grams 

80-120 

Water . 

200-300 c. c. 

.... 

Dextrose. 

20- 30 grams 

80-120 

Wine (white or red). 

15- 30 c. c. 

10-20 

Water . 

200-300 c. c. 

.... 

Boas recommends 



Milk. 

200 c. c. 

175 

Yolk of egg. 

2 

100 

Salt . 

A pinch 


Wine . 

15 c. c. 

10 

Elour . 

15 grams 

56 

Myer recommends 



Cream. 

250 c. c. 

500 

Peptone. 

25 grams 

? 

Pancreatin. 

5 grams 

.... 


tions. Tlie rectal tube should be oiled, freed of air by allowing the enema 
to fill it, and introduced well into the intestine. 

The size of nutrient enemata varies from 6 to 10 ounces (200 to 
300 c.c.) ; the larger the enema the less frequent the need of repetition. 
They should be given at temperatures of 95° to 100° E. Nutrient 
enemata should always be injected slowly. The flow may be regulated 
by raising or lowering the container. The sugar solutions are often given 
drop by drop, after the Murphy method. It is rarely advisable to give 
more than three enemata a day. 

The patient should be instructed to remain quiet afterward and to 
resist expulsion of the enema. Pressure upon the perineum with a folded 
towel by the attendant will often enable the patient to retain it when other- 
wdse it would be rejected. When the colon becomes irritated, 10 to 20 
drops of laudanum may be added to the enema in order to quiet the 
nervous reflexes set up by the irritation. 

Gavage.—The term “gavage” designates forced feeding through an 
esophageal tube. The tube may be passed through the mouth or the nose. 
Gavage is especially indicated in the case of hysterical or psychopathic 
patients who refuse food. It has also been employed in stricture of the 
esophagus, whether spasmodic or organic, in paralysis of the muscles of 
deglutition, and in comas. The practice of gavage is not unattended by 
danger, since the tube may enter the larynx, especially when the patient 
is unconscious, and cause pneumonia. Food should not be administered 























METHODS OF ARTIFICIAL FEEDING 


123 


in such cases oftener than once or twice a day. In the case of persons 
who are conscious, food may he given three times a day. 

Only liquid foods are suitable for gavage. The “meal” should be 
made up (as to bulk and energy value) according to the frequency with 
which it is to be repeated, and should be warmed to about the body tem¬ 
perature. Milk, cream, eggs, and sugars are best adapted to the method, 
and may be employed in the following or similar mixtures: 


Mixture Used for Gavage 


Food 

Quantity 

Calories 

Milk . 

1 pint (500 c. c.) 

350 

Cream. 

1 pint (500 c. c.) 

1,000 

Lactose or cane-sugar. 

50 grams 

200 



1,550 

Milk . 

1 pint (500 c. c.) 

350 

Cream. 

V 2 pint (250 c. c.) 

500 

Eggs . 

2 

160 



1,010 


Subcutaneous Feeding— Fats. —Leube first suggested the subucta- 
neous administration of oils and fats as a means of supplying the body 
with nutriment. Mills has recently made an extended study of the 
method in Lusk’s laboratory, and the following statements are based upon 
his results. 

Fats which are similar in composition to that of the body are most 
readily absorbed. Emulsions are absorbed better than plain oils. The 
best emulsion is made with from 3 to 5 per cent of egg-lecithin and sterile 
water. The site of the injection should be sterilized with tincture of iodin 
and should be massaged gently afterward. Care should be taken to avoid 
entering a vein, as cerebral or pulmonary fat embolism would result. 
If the emulsion is injected slowly into the subcutaneous tissues, 60 grams 
of oil may be given at one time without causing discomfort. Mills has 
proved that fats introduced subcutaneously may be burned directly, thus 
sparing the body fat, may be retained in the body in their own form, or 
may be reconstructed into body fat. 

The subcutaneous administration of fat should not be employed unless 
the patient is capable of taking food by mouth. While the method holds 
promise of being useful, it has not been perfected sufficiently to permit 
of its recommendation for general purposes. 

Protein and Sugar .—While numerous attempts have been made to 
administer proteins and sugar subcutaneously, the methods hitherto em¬ 
ployed have not proved practical. Native protein solutions are difficult 
















124 


NUTRITION AND DIETETICS 


to sterilize: proteoses and peptones are toxic. Solutions of glucose cause 
pain, and may cause necrosis, when given in greater concentration than 
5 per cent. The weaker solutions supply so little nourishment that the 
drawbacks to the method outweigh its advantages. 


THE SALT-POOR DIET 

The diet of civilized man contains ordinarily from 10 to 15 grams 
of common salt. This amount is readily excreted by normal kidneys in 
twenty-four hours. In some cases of nephritis, however, especially those 
of the parenchymatous type, the kidneys are unable to excrete more than 
2 or 4 grams, or even less, of salt a day. The salt which is retained 
passes into the tissue fluids and causes, or increases an existing, edema. 
The inability of the kidneys to excrete salt sometimes runs parallel with' 
an inability to excrete water. 

The excretory power of the kidneys for salt may be tested by a diet 
of 3 liters of milk (this contains 5 grams sodium chlorid and 100 grams 
protein) or by Strauss’ diet, consisting of % liter of milk, 4 eggs, 150 
grams of bread, and enough fruit, fruit juice, tea, and sugar to make 
it palatable. Strauss’ diet contains about 3 grams of salt. If the kidneys 
are able to excrete the amount of salt contained in these diets, salt may 
be added to either of them in quantities of 5 to 10 grams. When the 
kidneys are unable to eliminate the normal quantity of salt, some form 
of salt-poor diet may be advised, but it should be stated that the salt-poor 
diet has not entirely fulfilled the promises held out for it. 

A salt-free diet is a practical impossibility unless one follows von 
Noorden’s plan of giving 200 grams of lactose only. The salt-poor diets 
have been grouped under three headings: 

The strict salt-poor diet of Widal (containing 1.5 to 2.5 grams of 
salt) consists of salt-free bread 200 grams, meat 200 grams, vegetables 250 
grams, butter 50 grams, and sugar 40 grams. This diet contains 60 
grams of protein, and furnishes 1,500 calories, which is nearly sufficient 
energy for the average patient resting quietly in bed. 

The medium strict diet contains from 2.5 to 5 grams of salt. The 
milk diet (3 liters) belongs here. The food should be cooked without 
the addition of salt, but the patient should be allowed to use 2 to 3 grams 
of salt a day at the table. 

The moderate salt-poor diet (5 to 10 grams) allows considerable lati-. 
tude. It is not necessary to prepare special dishes, but the cook should be 
instructed to use salt sparingly. Salted foods, such as bacon and ham, 
should be prohibited. This diet furnishes only a rough control of the 
salt intake. 

In administering a salt-poor diet, it is important that the energy 


THE SALT-POOR DIET 125 

value of the food should not he permitted to fall below, nor to greatly 
exceed, the daily requirement of the patient. 

In addition to its employment in nephritis, the salt-poor diet has been 
recommended for the edema of chronic cardiac valvular disease, for the 
ascites of cirrhosis of the liver, pleurisy with effusion, arterial sclerosis, 
and diabetes insipidus. 


Salt Content of Foods 


According 


Food 

Per Cent 
Sodium 

Chlorid in 
Raw 
Material 

Meats 

Mutton . 


Veal . 


Calf’s brain . 

.. 0.20 

Calf’s kidney.. 


Calf’s liver. 


Beef (lean).. 

... 0.11 

Pork (lean). 


Venison. 


Fish 

Trout . 


Halibut . 


Herring.. 


Cod. 

,.. 0.16 

Carp . 


Salmon.. 

... 0.061 

Mackerel . 

... 0.28 

Haddock .. 

.. . 0.39 

Oyster (washed).. 

.. . 0.52 

Oyster (with sea water) .. 

,.. 1.14 

Poultry 

Duck. 

,.. 0.14 

Goose . 

,.. 0.20 

Chicken . 

.. 0.14 

Pigeon .. 

.. . 0.15 

Turkey.. 

... 0.17 

Smoked and Salted Foods 

Ham (raw). 

.4.15—5.86 

Ham (boiled). 

.1.85—5.35 

Salmon (smoked). 

,. . 7.50 

Bacon (smoked, German). 

. . 1.01 

Bacon (smoked, American). 11.61 

Corn beef, German. 

. . 2.04 

Corn beef, American. 

.. 11.52 

Cod (salt) *. 

.. 23.00 

Cod (salt, boneless) *. 

.. 19.00 

Herring (smoked) *. 

.. 11.70 


to Leva 

Per Cent 
Sodium 

Food Chlorid in 

Raw 
Material 

Smoked and Salted Foods—Cont. 
Mackerel (salt, dressed).... 10.40 
Salmon (smoked, salted).... 10.87 
Sardines (French, in oil). .. 1.34 


Cod-liver oil. 0.17 

Gelatin (dry). 0.75 

Beef marrow. 0.11 

Sausages, Frankfurter. 2.20 

Sausages, various kinds.. .2.90—8.10 
Anchovy paste (Cross & 

Blackwell).40.1 

Meat Extracts 

Liebig’s . 2.60 

Kemmerich. 1.40 

Various bouillon capsules, 

extracts, etc.9.40—22.0 

Prepared Foods 

Plasmon. 0.21 

Roborat . 0.0051 

Sanatogen. 0.42 

Somatose. 0.66 

Bovril’s preparations.0.26—14.1 

Valentine’s Meat Juice... .0.08—1.20 

Egg (white and yolk). 0.21 

Egg (white alone). 0.31 

Egg (yolk alone). 0.039 

Caviar . 3.00 

Milk (whole). 0.16 

Cream . 0.13 

Buttermilk . 0.16 

Whey.0.11—0.15 

Condensed Milk. 0.40 

Butter (unsalted).0.02—0.21 

Butter (salted).1.00—3.00 

Peanut butter *. 4.10 

Oleomargarine. 2.15 

Palmin. 0.0016 

Fructin . 0.10 


Analyses from Atwater and Bryant. 






























































126 NUTRITION AND DIETETICS 


Salt Content of Foods (Continued) 


Food 


Cheese 

Parmesan . 

Swiss . 

American, pale*. 

Pineapple cheese. 

Edam . 

English cream cheese. 

Infant’s Foods 

Nestle’s Food.. 

Rademan’s .. 

Robinson’s Patent Groats. 
Bread, etc. 

Graham bread. 

Pumpernickel. 

White bread. 

Zwieback .. 

Macaroni. 


Per Cent 
Sodium 
Chlorid in 
Raw 
Material 


, 1.93 

, 2.00 
0.82 
, 2.13 

, 3.30 

.70—1.15 

, 0.29 

, 0.03 

Trace 

, 0.61 
. 0.46 

.18—0.70 
. 0.38 

. 0.067 


Cereals, etc. 

Barley . 0.037 

Oats . 0.046 

Rye. 0.014 

Wheat . 0.013 

Rice . 0.039 

Corn (maize). 0.019 

Wheat flour.0.002—0.008 

Oatmeal (American). 0.29 

Oatmeal (German). 0.28 

Quaker Oats. 0.082 

Sago . 0.19 

Vegetables 

Potatoes .0.016—0.078 

Beets. 0.058 

Beans.!. 0.09 

Peas . 0.058, 

Lentils.0.13—0.19 

Lentils (dried). 0.155 

Artichokes. 0.036 

Cauliflower.0.05—0.15 

Cucumber (fresh).0.06—0.08 

Horse-radish .0.02—0.06 

Radish . 0.075 

Celery, stalks.0.25—0.49 

Celery, roots. 0.089 

Asparagus.0.04—0.06 

Spinach.0.084—0.21 

Tomatoes. 0.094 


Food 


Per Cent 
Sodium 
Chlorid in 
Raw 
Material 


V egetables—Con t. 

Cabbage .0.11—0.44 

Onions .0.016—0.09 

Canned Vegetables 

Green corn *. 0.40 

Green peas*. 0.70 

Tomatoes * . 0.10 

Mushrooms.0.04—0.06 

Fruits 

Pineapple. 0.071 

Orange .0.0057—0.0550 

Apricot. 0.0047 

Lemon . 0.0045 

Strawberry.0.0100—0.020 

Chestnuts.0.0045—0.010 

Cherry .. ... 0.013 

Coconut juice. 0.035 

Olives .0.008—0.210 

Plum . 0.0046 

Gooseberry . 0.021 

Watermelon juice. 0.011 

Grape. 0.024 

Almonds, dry. 0.010 

Walnuts, dry. 0.019 

Cane sugar. 0.110 

Lump sugar.. 0.049 

Chocolate (Lindt). 0.73 

Spices 

Capers (preserved in salt).. 2.10 

Capers (preserved in vine¬ 
gar) . 0.20 

Pepper, black. 0.51 

Pepper, white. 0.019 

Mustard. 2.66 

Vanilla. 0.055 

Cinnamon . 0.061 

Cocoa beans.0.05—0.095 

Coffee (roasted). 0.045 

Tea. 0.15 

Drinks 

Ground water.0.0012—0.0060 

Spring water.0.00055—0.0046 

Ale . 0.0017 

Beer (German). 0.016 

Beer (English). 0.10 

Champagne (Moet & Chan- 
don) . 0.0045 


Analyses from Atwater and Bryant. 


















































































THE PURIM-FREE DIET 127 

Salt Content of Foods ( Continued ) 


Per Cent 

_ Sodium 

Chlorid in 
Raw- 
Material 

Drinks—Cont. 

Apollinaris . 0.043 

Fachinger . 0.039 

Giesshiibel (Mattoni). 0.0021 

Vichy . 0.053 

Foods Prepared for Table 

Bouillon .0.5—1.0 

Thick soups. 0.54 

Roast beef. 0.98 

Roast pork. 1.54 

Chops. 0.97 

Roast chicken. 0.39 


Per Cent 
Sodium 

Food Chlorid in 

Raw 
Material 

Foods Prepared for Table—Cont. 

Sauces..0.7—1.5 

Scrambled eggs (salted) .... 1.10 

Spinach . 0.91 

Carrots . 0.46 

Cauliflower . 0.49 

Green salad. 0.41 

Apple sauce.. 0.031 

Stewed pears. 0.019 

Tapioca pudding (unsalted) 0.026 
Macaroni (a la Napolitaine) 1.04 
Rice with apples. 0.18 


THE PURIN-FREE DIET 

Purin bodies preexist in the food and are formed within the body. 
The former are designated exogenous, the latter endogenous purins. Both 
animal and vegetable foods contain purins. Those of greatest interest to 
the physician are guanin, adenin, hypoanthin, xanthin, uric acid, caffein 
(thein), and theobromin. The ingestion of exogenous purins raises the 
purin-content of the urine, and in proportion to the amount taken, but 


Purin Content of Foods (Reckoned as Uric Acid) 
According to Schmid and Bessau, Walker Hall, and Hesse 


100 Grams 

Uric Acid Grams 

100 Grams 

Uric Acid Grams 

Beef. 

.0.111—0.189 

Salmon . 

. 0.072—0.201 

Mutton . 

. 0.078—0.191 

Carp . 

.0.162 

Pork . 

.0.123—0.185 

Herring . 

.0.207 

Veal . 

.0.114—0.189 

Sardines in oil. 

. 0.354 

Ham (raw). 

. 0.072—0.139 

Anchovy. 

.0.465 

Tongue (calf). 

. 0.165 

Oysters . 

. 0.087—0.217 

Brain (pig). 

. 0.084—0.233 

Lobsters . 

.0.066 

Liver (beef). 

. 0.279—0.372 

Caviar. 

. 0.110 

Kidney . 

. 0.240—0.320 

Cauliflower . 

. 0.024 

Thymus (calf). 

. 0.990—1.308 

Spinach . 

. 0.072 

Chicken . 

. 0.087—0.186 

Celery . 

.0.015 

Pigeon. 

. 0.174—0.154 

Asparagus . 

. 0.024—0.057 

Goose. 

. 0.099 

String beans. 

.0.006 

Venison . 

. 0.117—0.182 

Potatoes . 

.0.006 

Bouillon .. . 

. 0.045—0.151 

Mushrooms . 

.0.015—0.019 

Meat Extract. 

. 2.000—5.000 

Peas. 

. 0.054—0.079 

Trout . 

.0.213 

Lentils.... . 

. 0.075—0.162 

Shellfish . 

.0.117 

Beans . 

. 0.051—0.098 

Cod . 

. 0.067—0.131 

Oatmeal . 

.0.064 


























































128 


NrUTKITION AND DIETETICS 


less is excreted than is ingested. The excretion of endogenous pur ins is 
essentially constant for each individual. 

The use of the purin-free diet is based upon the theory that gout and 
some other disorders are dependent upon the retention of uric acid in 
the body. The diet has also been employed in diseases of the kidney, for 
some headaches, and “bilious attacks.” (Proof is lacking, however, that 
the diet possesses definite value.) 


Foods Containing No Purins 


Bread 

Beets 

Cereals 

Onions 

Fruits 

Port 

Eggs 

Sherry 

Milk 

Bordeaux 

Cheese 



Purin Content of Beverages 


According to Walker Hall and Labbe 




Purin Bodies 
Reckoned as 
Uric Acid in 


Purin Bodies 
Reckoned as 
Uric Acid in 


100 Grams 

Grams 

Chiefly 

Methylpurins 

100 Grams 

Grams 

Chiefly 

Methylpurins 

Coffee 

(roasted). 

1.24 

1 Cup tea (Ceylon). 

. 0.0805 

Tea . . 


_ 1.35—3.58 

1 Cup tea (Indian). 

. 0.0700 

Chocolate. 

1.43 

1 Cup tea (Chinese). ... 

.0.025—0.046 

Cocoa 


_ 1.30 

1 Cup coffee. 

.0.110—0.250 

Beer . 


0.016 

1 Cup chocolate. 

1 Cup cocoa (10 grams). 

.0.268—0.572 

0.130 


Purin Nitrogen Content in Per Cent 
From Vogel 


Purin N 


Beef* . 0.059 

Beef liver.. :. 0.099 

Beef thymus. 0.398 

Cod* . 0.040 

Wheat meal. 0.001 

White bread. 0.008 

White bread *. 0.005 

Hominy. 0.004 


Purin N 


Oatmeal. 0.030 

Bice*. 0.0004 

Potatoes * . 0.001 

Spinach * . 0.022 

Milk . 0.0002 

Swiss Cheese. 0.0004 

Egg. 0.0 

Tomatoes * . 0.0 


* Foods bought in America. 


METABOLISM IN FEVER 

Total Metabolism. —The loss of weight, which until recently has 
always accompanied prolonged high fever, early led to the belief that 
the intensity of the metabolic processes in fever is increased. This belief 





























METABOLISM IN FEVER 


129 


remained unchallenged for many years, in fact, until attempts were made 
to calculate the heat production of patients with fever from measure¬ 
ments of the respiratory exchanges. 

The increase of the nitrogen excretion in the urine has generally 
been accepted as indicating a more rapid destruction of protein. The 
discussions have centered around the total heat production and the extent 
to which carbohydrate and fat participated in the metabolic processes, 
which bring about the increased heat production. 

A rise of the body temperature may he brought about by an increase 
in heat production without change in heat elimination, by a decrease in 
heat elimination, the heat production remaining unchanged, or by other 
disproportional alterations of heat production and heat elimination. In 
probably no disease does the heat production reach such levels as nor¬ 
mally occur during violent and prolonged muscular exertion, yet the body 
temperature is not affected by it. In exophthalmic goiter the metabolism 
may be 75 per cent above normal without producing fever. Therefore, 
it is evident that increase in heat production alone is not sufficient to 
cause fever. The heat regulating mechanism must be altered. It is “set” 
in fever for a higher level of body temperature just as a thermostat is 
set for a higher temperature in an incubator. 

Quantitative Changes.—The total heat production of the body may 
be learned by direct measurement of the heat given off (direct calorimetry) 
or be calculated from the respiratory exchanges and the nitrogen of the 
urine (indirect calorimetry). Du Bois has shown with the aid of the 
calorimeter of the Russell Sage Institute of Pathology that the two 
methods agree within 2.2 per cent. 

The earliest studies of the total heat production in fever by indirect 
calorimetry gave inconstant results. In the majority of cases an increase 
was noted, but other cases were observed in which it was normal or even 
decreased. As a result of these differences the theory was advanced that 
fever might occur without increase in heat production, that is, from de¬ 
crease in heat elimination. But the results obtained in the investigations 
of Coleman and Du Bois, and the fact that many of the earlier obser¬ 
vations have been proved unreliable, inclined the author to the belief 
that fever is always accompanied by increased heat production. There 
has always been an increase during the febrile period of typhoid. The 
total metabolism was roughly parallel to the temperature curve, though 
there were considerable variations in different patients and in the same 
patient at different stages of the disease. The average increase amounted 
to 40 per cent, the maximum to something over 50 per cent. 

Without entering into the discussion of the significance of fever in 
the infective diseases, some of the factors to which the increase in heat 
production has been attributed require consideration. 

An early explanation ascribed the increase to the greater destruction 


130 


NUTRITION AND DIETETICS 


of protein. This theory has been abandoned except in so far as the 
protein metabolism contributes to the general increase. 

Er. Mueller suggested that the increase in metabolism might be 
due in part to the increased rapidity of the heart and respiration and to 
muscular effort—restlessness, rigors. The most recent studies indicate 
that the amount of energy liberated by the heart and muscles of respira¬ 
tion is insignificant when compared to the total; at least, it plays no con¬ 
siderable part in increasing heat production in fever. In typhoid the 
pulse is characteristically slow. But few observations have been made 
on the amount of energy required to perform muscular work in fever. 
Svenson found in convalescence from typhoid that muscular work is not 
done economically. It may not he done economically during the febrile 
period, yet according to evidence which we possess the increase in total 
metabolism is greater than could he accounted for by restlessness. A 
patient was unusually quiet during the first hour of a three-hour period 
in the calorimeter; during the second hour he was restless and tossed 
about the bed; during the third hour he was restless and irrational. 
Yet during the whole period his metabolism was only 43 per cent above 
normal, and was only 5 per cent higher than it was during a quiet 
observation made two days later when the temperature was lower. In 
the typhoid state, when the patient is rarely quiet, the increase in heat 
production from muscular effort must be great—it is conceivably doubled. 
In the ordinary case of typhoid the amount of the increase from moving 
about the bed has been estimated to be about 10 per cent. 

The influence of food upon the total metabolism during the febrile 
period is negligible. The increase from protein is 5 per cent, from 
carbohydrate 1 per cent. In convalescence food has caused an increase of 
16 per cent in heat production, but without affecting the body temperature. 

Qualitative Changes.—When the nitrogen of the urine is known, the 
amounts of protein, carbohydrate, and fat consumed during stated periods 
may be calculated from the 0 2 consumption and the respiratory quotient. 
The respiratory quotient, or coefficient, is the result obtained by dividing 
the C0 2 output by the 0 2 consumed. 

By reason of its chemical composition, when carbohydrate is oxidized 
to carbon dioxid and water the amount of CO^ liberated and 0 2 con¬ 
sumed are equal and the respiratory quotient is 1.0. When fat is oxidized 
to the same end-products the respiratory quotient is 0.7. When protein 
is oxidized to urea the quotient is 0.8. When the body transforms carbo¬ 
hydrate to fat the quotient is over 1.0, because fat is poorer in oxygen 
than is carbohydrate. Since under actual conditions some protein is con¬ 
stantly metabolized, the respiratory quotient may vary from something 
over 0.7 to somewhat under 1.0. When the body is storing fat the quotient 
is slightly under, or over, 1.0. 

The respiratory exchanges of fever patients have been studied both 


METABOLISM IN FEVER 


131 


during the fasting state and after food. The data which have been ac¬ 
cumulated permit a reasonably clear conception of metabolic processes in 
fever to be formulated. 

The low respiratory quotients, that is, under 0.7, which have been 
obtained by some observers, and which can only he interpreted by assum¬ 
ing that profound changes occur in the metabolic processes in fever, are 
now attributed to errors in technic. 

As will be seen later, the nitrogen metabolism probably is increased. 
But no qualitative change in the nitrogen metabolism has been observed. 
Protein is oxidized to the same end-products as in health—urea princi¬ 
pally—and liberates the standard amount of heat per unit of substance. 
No qualitative changes are known in the metabolism of carbohydrate and 
fat. Both are oxidized to carbon dioxid and water and, similarly, produce 
the calculated amounts of heat. The law of the conservation of energy 
obtains in fever as well as in health. 

The respiratory quotients prove that carbohydrate and fat are 
metabolized under the same general laws as in health—only the rate of 
utilization is changed. When available, carbohydrate is consumed in 
preference to, and in greater quantity than, fat, just as in health when 
an increased demand for energy has to be met. When carbohydrate is 
not available, fat (of the food or body stores) is utilized. It is still doubt¬ 
ful whether fat is as capable of protecting body protein as is carbohydrate. 
In a mixed diet they appear to be equally good as protein-sparers, within 
limits which have not yet been determined. The carbohydrate supply is 
more rapidly exhausted in fever than in health, whether in the form 
of the unchanged carbohydrate of the blood or the glycogen of the tissues, 
and should he frequently replenished. 

Nitrogen Metabolism.—On low diets the nitrogen metabolism is al¬ 
ways increased in the infective fevers. More nitrogen leaves the body in 
the urine than is taken in with the food. Consequently, the store of 
nitrogen is constantly depleted; the patient is said to he in negative 
nitrogen balance. In severe forms of the infective fevers, such as pneu¬ 
monia and typhoid, the losses, relatively speaking, may be very great. 
In general, the extent of the loss is proportional to the severity of the 
infection. It is always greater than in simple starvation. 

This loss of nitrogen' in the infective fevers has been known for many 
years and has been called the febrile or toxic destruction of protein . 
Accordingly, it has been considered a characteristic phenomenon of infec¬ 
tive fevers. 

Several conceptions of the nature of the process are found in the exten¬ 
sive literature on the subject. Von Leyden and Klemperer describe it 
as a loss of nitrogen which cannot he prevented by food. According to 
Benedict and Suranyi, it is merely an expression of the increase in total 
metabolism. Krehl and Fr. Mueller use the term to indicate direct 


132 


NUTRITION AND DIETETICS 


injury to the cells of the body by the toxin of the infecting organism. 
These different conceptions have led to much confusion in discussions of 
the subject. It should he stated here that Grafe and his pupil, Rolland, 
deny the existence of a toxic destruction of protein in fever. 

By their success in bringing patients with severe attacks of typhoid 
fever into nitrogen equilibrium, Shaffer and Coleman showed that the 
conception of von Leyden and Klemperer is no longer tenable. 

The main objection to the theory of Benedict and Suranyi lies in the 
fact that the nitrogen metabolism of normal men does not rise with the 
increase in total metabolism which occurs during muscular effort. More¬ 
over, the increase in nitrogen metabolism appears to he greater than can 
he explained by the increase in total metabolism in fever. 

Krehl’s theory of the toxic destruction of protein is at present the 
center of active discussion. The opponents of the theory, when not deny¬ 
ing its occurrence, maintain that the increase in nitrogen metabolism is 
due to the rise in the body temperature rather than to an injurious action 
of toxins on the cells. 

Influence of High Temperature .—A large number of experiments 
have been performed on lower animals and man in the attempt to dis¬ 
cover the extent to which nitrogen metabolism is influenced by high 
temperature. The body temperature has been raised artificially by punc¬ 
ture of the heat center, by hot-air, hot-water, and steam baths, and the 
nitrogen output determined. The nitrogen output of patients with various 
types and heights of temperature curves has been studied during the 
febrile and afebrile periods. 

The results of these experiments have not been uniform. Senator 
and Richter explain negative results by saying that increase in the 
metabolism of protein occurs only when the high temperature is main¬ 
tained for a number of hours, and that the increase of nitrogen in the' 
urine may not at once he apparent. Graham and Poulton, experiment¬ 
ing upon themselves, did not succeed in increasing the nitrogen output 
by raising the body temperature by steam baths. 

The observations in various febrile diseases and on experimentally 
infected animals have been equally inconstant. In some instances the 
nitrogen excretion has paralleled the temperature curve; in some it has 
been high when the temperature has been low, and an increase in the 
nitrogen excretion has been observed before the rise in temperature oc¬ 
curred. Linser and Schmid state that the nitrogen excretion is affected 
only by temperatures of 39° C. and over. 

Influence of Toxins .—The discrepancies in the relation of the nitro¬ 
gen excretion to the body temperature led to a search for other causes. 
Krehl attributes the increase in nitrogen metabolism to a deleterious 
action of the toxin of the invading organism on the cells of the body. 

Commenting on May’s experiments on animals, Er. Mueller says the 


METABOLISM IN FEVER 


133 


fact that carbohydrate diminishes the protein loss in fever would not 
disprove the theory of a toxic destruction until it had been shown that 
like amounts of carbohydrate reduce the nitrogen exchanges of men with 
high fever to as low a level as in health. Shaffer and Coleman have 
shown that this is impossible in typhoid fever. Their patients could not 
he brought into nitrogen equilibrium until they were given amounts of 
food representing an energy value of 50 per cent to 100 per cent above 
their heat production (computed from measurements made later with the 
Benedict “universal” apparatus and the Sage calorimeter). It was also 
found that the nitrogen intake could not be reduced much below 10 grams 
without throwing the patient out of nitrogen balance. Rolland’s patients 
with sepsis, paratyphoid, and acute pulmonary tuberculosis had a nitrogen 
metabolism not greater than the lowest requirements in health. She 
brought them into balance on amounts of protein slightly greater, or 
within the figures given by Rumpf and Schumm (1.15 grams per kilo¬ 
gram) and by Chittenden (0.7 grams per kilogram), but with an excess of 
carbohydrate. She did not take the nitrogen minimum into consideration, 
that is, the smallest amount of nitrogen to which a healthy man can be 
reduced for short periods, together with sufficient amounts of carbohydrate 
and fat to cover his energy requirement, without developing a negative 
nitrogen balance. 

Recently Kocher, working under Fr. Mueller’s direction, has made a 
further study of the subject. He compared the effect of an increase in 
the total metabolism (through strenuous exercise) of two healthy indi¬ 
viduals upon their nitrogen minima with the nitrogen excretion of fever 
patients on diets containing essentially the same quantities of protein 
and amounts of energy, which, he calculated , were sufficient to bring them 
into nitrogen equilibrium. Since the fever patients lost nitrogen, while 
the healthy men did not, he concluded that the occurrence of a toxic 
destruction had been established. Kocher’s experiments are open to the 
objection that he did not first bring his patients into equilibrium and 
then reduce the protein, as Shaffer and Coleman did. Grafe has published 
experiments on animals which, he claims, disprove Kocher’s conclusion. 

The author believes that the protein metabolism is increased in the 
infective fevers. The fact that typhoid patients cannot be brought into 
nitrogen equilibrium unless they receive from 10 to 15 grams of nitrogen 
a day, and an amount of energy from 50 per cent to 110 per cent greater 
than their heat production, can, in his opinion, be interpreted in no other 
way. But whether the increase in protein metabolism is due to the eleva¬ 
tion in temperature or to injury from the toxins is, likewise in his opinion, 
an open question. 

The most important consideration for the practitioner is that it is 
possible to nourish fever patients in a manner which prevents loss of 
nitrogen to the body. 


134 


NUTRITION AND DIETETICS 


Absorption of Food in Fever.—Von Hoesslin found in 1882 that food 
is absorbed by typhoid patients almost as well as in health, in spite of the 
fact that most of his patients suffered from diarrhea. About the same 
time (1883) similar observations were made in Chudnowsky’s clinic in 
Russia. Von Leyden and Klemperer’s patients with high fever lost in 
the stools 6 per cent to 11 per cent of fat and 9 per cent of protein. No 
carbohydrate was lost except when large amounts were given or the patients 
had profuse diarrhea. Recently Du Bois has reinvestigated the question 
of food absorption in typhoid fever, using more reliable methods of 
analysis. He found the losses to be as follows: There was no loss of 
carbohydrate except when the patients were taking more than 300 grams 
a day; then it amounted to only 2 or 3 grams; the average loss of protein 
was 7 per cent; the average loss of fat for all stages of the disease was 
6 per cent (the loss of normal controls on the same diet was 3 per cent) ; 
for the early stages the loss was 7 per cent, for the later 4.5 per cent. 
It should be added that the patients were taking large amounts of fat. 
In Coleman and Gephart’s typhoid patients the average fat loss in all 
periods of the disease was 4.3 per cent. No differences were observed 
between the early and later stages. The nitrogen losses averaged 11 
per cent. 

These observations prove that in typhoid fever, and probably in other 
febrile diseases, the absorption of food is nearly as complete as in health. 

Fever Diet 

The facts which have been obtained through studies of metabolism 
in fever have removed all doubt that patients with fever require more 
food than healthy men, unless engaged in heavy labor. The only question 
is whether fever patients can take the amount of food they need without 
detriment. The answer is to be found in clinical tests, without which it 
is impossible to estimate the value of any therapeutic procedure. These 
tests have been made on a large scale, and the results prove not only 
that fever patients can take without harm the amount of food they need, 
but that they are benefited by doing so. 

Diets which do not furnish enough energy to cover the patients’ heat 
production compel them to live in part at the expense of their own tissues. 
Experiments with such diets extend back some 2,000 years in medical 
history, and the results, to say the least, have been disappointing, and the 
old doctrine of “starving a fever” is fundamentally erroneous. 

The food needs of the fever patient may be summarized as 
follows: 

The total energy required is always greater than in health. In gen¬ 
eral, the higher the temperature, the greater the need for food. In 
typhoid fever the body protein is not protected unless the food furnishes 


METABOLISM I1ST FEVEK 


135 


from 50 to 110 per cent more energy than the heat production. This is 
probably true for many infective fevers. There is some disagreement 
whether patients should be given such large amounts of food, but patients 
digest them well, and the author can see no justification for permitting a 
gratuitous loss of protein. Expressed as energy, patients with severe 
fever require from 3,000 to 4,000 calories a day. If they complain of 
hunger, as typhoid patients frequently have while taking this amount, 
the food may be increased. The author has permitted as much as 7,600 
calories. 

The amount of protein which the patient needs varies from 60 grams to 
90 grams. Patients lose nitrogen if less than 60 grams be given, and they 
derive no benefit from more than 90 grams. 

Carbohydrate is consumed in preference to fat, whenever it is avail¬ 
able, and should be the main reliance for maintaining the energy value 
of the diet. When the desired amount of carbohydrate is not easily 
digested, the quantity of fat may be gradually increased. The arrange¬ 
ment of dietaries will be simpler if fat is included (butter and cream), 
and with some patients it must be depended upon to supply the greater 
portion of the energy. As much as 300 grams of fat a day has been 
given. 

One of the most important considerations in the dieting of fever 
patients is individualization. Every effort should be made to “feed the 
fever,” but this can be accomplished only if the patient digests and absorbs 
the food he receives. With so many foods from which to choose, it will 
rarely be necessary to insist upon a patient’s taking foods he dislikes. 
His desires should be followed as far as is feasible both in the selection 
and preparation of his food. 

Foods which disagree should be avoided. Torrey has shown that the 
inability of the typhoid patient to digest his food is associated with a 
predominance of a putrefactive flora in the intestine. The equally im¬ 
portant fact, disclosed by his investigation, was that favorable fermen¬ 
tative types of organisms usually gain the ascendency on diets rich in 
carbohydrate. 

Much greater variety in food may be allowed than was formerly 
thought permissible. 

The author has practically abandoned the use of the milk diet except 
for brief periods and under unusual circumstances. Milk is a valuable 
addition to many dietaries, but, alone, it furnishes too much protein and 
too little energy. If a carbohydrate is taken with it, such as bread, 
crackers, simple cake, it is not only more easily digested but patients 
enjoy it more. Milk may serve also as a vehicle for other foods—milk- 
sugar, eggs, and cream. 

The food should be served as far as possible in the form and manner 
most likely to stimulate the patient’s desire for it. Small quantities at 


136 


NUTRITION AND DIETETICS 


frequent intervals—but not oftener than every two hours—are digested 
more easily than fewer, hut larger, meals. In severe fevers the patient 
should be waked for his food, except perhaps during the early morning 
hours. 

The appetite may be stimulated and flow of gastric juice started 
by beginning the larger meals with two to four ounces of meat soup. 
This amount will not compromise stomach room. 

The foods which the author has found most useful are: milk, cream, 
eggs, bread or toast, crackers, well-boiled and bran-free cereals, rice, well- 
cooked potato, butter, bacon (as a relish), milk-sugar, cane-sugar, tea 
and coffee (as vehicles and for variety), cocoa, apple sauce, orange juice, 
lemonade, and grape juice. 

Any digestible combination of these foods may be given (see Invalid’s 
Dietary). 

The more easily digested meats may he permitted in small quantities 
once a day, preferably at midday. Foods containing cellulose may be 
allowed to patients whose alimentary tracts are not the seat of pathologi¬ 
cal processes. 


INVALID’S DIETARY 

Oatmeal Gruel (plain) (from Food). —Two tablespoonfuls of granu¬ 
lated oatmeal (45 grams, 184 calories), one saltspoonful of salt, one scant 
teaspoonful of sugar (8 grams, 33 calories), one cupful of boiling water, 
one cupful of milk (300 grams, 216 calories). Mix the oatmeal, salt and 
sugar together, and pour on the boiling water. Cook for thirty minutes; 
then strain through a fine wire strainer to remove the hulls, place again on 
the stove, add the milk, and heat just to the boiling point. Serve hot. 

This gruel furnishes 125 calories. 

Barley Water (Cautley)— Thin. —Put a teaspoonful of prepared or 
pearl barley, previously washed in cold water, into a jug, pour half a 
pint of boiling water on it; add a pinch of salt; stand it by the fire for an 
hour, stirring occasionally, and strain through fine muslin. Similar thin 
cereal decoctions may be made from rice, arrowroot, or oatmeal. It fur¬ 
nishes about 7 calories per 100 c.c. 

Thick. —Put a heaped tablespoonful of washed, prepared, or pearl 
barley into a clean sauce-pan and add a quart of water and a pinch of 
salt. Boil slowly until it has evaporated down to about two-thirds of a 
quart and strain. It may be flavored as desired. The addition of a 
little lemon peel, while boiling, is best. 

The composition of barley water is: 0.09 per cent protein, 0.05 per 
cent fat, 1.6 per cent carbohydrate. 

It furnishes 1If calories to 100 c. c. 


INVALID’S DIETAEY 


137 


Toast Water (Cautley).—Pour a pint of boiling water over two or 
three slices of well-toasted bread. Let it stand until cool; strain. 

The calory value of this preparation is negligible. 

Chicken Broth (Bartholow).—Skin and chop fine a small chicken 
or half of a large fowl, and boil it, bones and all, with a blade of mace, 
a sprig of parsley, and a crust of bread, in a quart of water for an hour, 
skimming it from time to time in order to remove the excess of fat from 
the broth. Strain through a coarse colander. 

The composition of chicken broth is: 84.3 per cent water, 10.5 per 
cent protein, 0.8 per cent fat, 2.4 per cent carbohydrate, 2 per cent ash. 

It furnishes 56 calories to 100 c. c. 

Chicken Jelly (Adams).—Clean a fowl that is about a year old, re¬ 
move skin and fat; chop bones and flesh fine, place in a pan with two 
quarts of water; heat slowly; skim thoroughly; simmer five to six hours; 
add salt, mace, or parsley to taste; strain, and cool. When cool, skim off 
the fat. The jelly is usually relished cold, but may be heated. Data for 
estimating the calory value of this preparation are not available. 

Beef Tea (Cautley).—1. Mince one pound of lean beef, and add to 
it one pint of cold water and ten drops of dilute hydrochloric acid. Let 
it stand for two or three hours, with occasional stirring, and then simmer 
for ten to twenty minutes. Do not let it boil. Skim well. 

2. Mince one pound of lean beef as fine as possible, and pound it in a 
mortar with a small teaspoonful of salt. Add the meat and its juice 
to one pint of water at 170° F. in an earthen vessel, and stand it for an 
hour by the fire, stirring at times. Then strain it through muslin, taking 
care to squeeze all the juice out of the meat. 

The composition of beef tea is: 92.9 per cent water, 4.4 per cent 
protein, 0.4 per cent fat, 1.1 per cent carbohydrate, 1.2 per cent ash. 

It furnishes 25 calories to 100 c. c. 

Invalid Broths (Thompson).—To one pound of chopped lean meat, 
either chicken, mutton, or beef, add one pint of cold water; let stand in a 
covered glass fruit jar from four to six hours; cook for three hours in a 
closed jar over a slow fire, strain, cool, skim off the fat, clear with egg, 
season, and feed warm or cold. 

These broths, except the chicken broth, possess essentially the same 
fuel value as beef tea. 

Beef Juice (Bartholow).—Broil quickly some pieces of round or sir¬ 
loin steak, of a size to fit in the cavity of a lemon squeezer previously 
heated by dipping in hot water. The juice should be received into a hot, 
colored (preferably red) wine glass, seasoned to taste with salt and 
cayenne pepper, and taken hot. 

Beef Juice (Cautley).—Chop lean beef fine, or scrape with a fork 
or meat scraper to separate the connective tissue, and put it in a jar or 
cup, with a pinch of salt and enough cold water to cover it. Allow 


138 


NUTRITION AND DIETETICS 


it to stand from one to six hours, and then squeeze well through coarse 
muslin. It may he given alone or mixed with other foods, warm 
or cold—not hot. It should be warmed by heating the vessel in hot 
water. 

Beef Juice (Ringer).—Take one ounce of fresh beef, free from fat, 
chop fine, and pour over it eight ounces of cold water; add five or six 
drops of dilute hydrochloric acid, and fifty to sixty grains of common salt, 
stir it well, and leave for three or four hours in a cool place. Then pass 
the liquid through a hair sieve, pressing the meat slightly, and adding 
gradually toward the end of the straining about two more ounces of 
water. The liquid thus obtained is of a red color, possessing the taste of 
soup. It should he taken cold, a teaspoonful at a time. If preferred 
warm, it must not he put on the fire, but heated in a covered vessel placed 
in hot water. 

The composition of beef juice is: 90.6 per cent water, 5.0 per cent 
protein, 0.6 per cent fat. 

It furnishes 25 calories to 100 c. c. 

Beef Pulp (Cautley).—Scrape a piece of raw lean rump or sirloin 
steak with a fork or meat scraper until as much as possible of the muscu¬ 
lar tissue has been obtained, separated from the tendinous parts. Pound 
it in a mortar to a pulp, and then rub it through a fine sieve. Sea¬ 
son with pepper and salt. It may he taken in the form of sandwiches, 
or rolled up into small rissoles and lightly grilled or fried. 

Very little of the nutriment of the meat is lost in this process. 

Egg-Albumin Water (Watson).—Take the white of an egg (30 
calories) and to it add twice its own volume of water and strain through 
muslin. This, gives about three ounces of a clear solution, containing as 
much protein as is found in the average sample of commercial beef 
juice. 

This fluid, added to home-made beef tea, makes a nutritive solution 
almost indistinguishable from beef juice and at a fraction of the cost. Mix 
while cool in order not to precipitate the proteins. 

Egg-Albumin Water (Cautley).—Take the white of a fresh egg (30 
calories) and cut it in numerous directions with scissors. Shake it up 
in a flask with a pinch of salt and six ounces of cold water. Strain 
through muslin. 

It can he made with thin barley water, and cream or sugar added. 

Egg-nog.—The following recipe makes a glass and one-half of egg¬ 
nog: 


Egg, 1 large (60 grams). 80 calories. 

Sugar, 1 tahlespoonful (30 grams). 120 “ 

Whisky, 2 tablespoonfuls. 90 “ 

Cream, 7 tablespoonfuls. 210 “ 






INVALID’S DIETARY 


139 


Add the sugar to the yolk of egg and heat until very light. Whip 
the white of the egg and then the cream until very stiff. Add the whisky 
to the yolk of egg and sugar. Mix well. Add one-half the cream to this, 
then one-half the beaten white of egg, then the remaining cream, and 
finally the remaining white of egg. Mix lightly. 

Egg-nog (Bartholow).—Scald some new milk by putting it, contained 
in a jug, into a saucepan of boiling water, but it must not he allowed to 
boil. Beat an egg with a fork in a tumbler with some sugar; add a 
dessertspoonful of brandy, and fill the tumbler with the scalded milk 
when cold. 

This egg-nog will furnish about 300 calories. 

Savory Custard (Anderson).—Add the yolks of two eggs to a cupful 
of beef tea, with pepper and salt to taste. Butter a cup or a jam pot, 
pour the mixture into it, and let it stand in a pan of boiling water till 
the custard is set. 

This will furnish 150 calories. 

Egg Flip. —Boil or heat thoroughly a teacupful of milk; heat the 
white of one egg to a froth. Pour the milk over the egg, stirring con¬ 
stantly. Add sugar to taste. 

This will furnish 230 calories. 

Caudle (Yeo).—Beat an egg to a froth; add a glass of sherry and 
half a pint of gruel. Flavor with a lemon peel, nutmeg, and sugar. The 
gruel may be made either with water or milk. 

This will furnish from 120 to 150 calories, according to the consist¬ 
ency of the gruel. If milk is used to make the gruel , it will have a higher 
value. 

Boiled Rice (U. S. Army Hospital Kecipe).—Rice, one ounce (30 
grams) ; salt, twenty grams; water, four ounces. Directions. —Put the 
salt and water into a stewpan. When boiling add the rice, previously 
washed thoroughly. Boil for ten minutes, or until each grain becomes 
soft. Drain it on a colander. Grease the stewpan with clarified drip¬ 
pings or lard. Put hack the rice. Let it swell slowly near the fire, or 
in a slow oven, for about twenty minutes, until the grains are well 
separated. 

Boiled rice furnishes 60 calories to 1 tablespoonful. 

Rice Pudding 

Rice 3 tablespoonfuls (100 grams) 360 calories 

Milk 1 quart 700 “ 

Salt 1 pinch 

Wash the rice with water. Add to the milk and cook slowly on top 
of the stove for one hour, or a little longer, until the mixture becomes 
creamy. 


140 


NUTRITION AND DIETETICS 


Add 

Sugar 1 cup (280 grams) 1,148 calories 

Butter 1 heaping teaspoonful 120 “ 

Cinnamon, nutmeg, or vanilla to taste 

Put into a dish to set' and bake in an oven until the top is browned. 

The whole pudding contains 2,325 calories. It furnishes five to six 
portions. 

Rice Pudding (Cautley).—Cover the bottom of a dish with clean 
rice, nearly fill with milk, and add sugar; put it in a slow oven for three 
hours, and in the hottest part of the oven for fifteen minutes. 

With the indefinite statement of the amounts of the ingredients, the 
calorie value of this preparation cannot be estimated. 

Rice and Egg Pudding (Cautley).—Take three ounces (90 grams, 315 
calories) of rice and swell it gently in one pint of new milk (350 calories). 
Let it cool, and stir well into it one ounce of fresh butter (230 calories), 
two ounces of powdered sugar (240 calories), the yolks of three eggs (150 
calories), and some grated lemon peel. Pour into a well-buttered dish 
and put on the top the whites of the three eggs (96 calories), beaten 
with three tablespoonfuls of powdered sugar (185 calories). Bake for 
twenty minutes until lightly browned. 

The whole pudding contains 1,550 calories. 

Arrowroot (Pavy).—Mix thoroughly two teaspoonfuls of arrowroot 
with three tablespoonfuls of cold water, and pour on them half a pint of 
boiling water, stirring well meanwhile. If the water is quite boiling, the 
arrowroot thickens as it is poured on, and nothing more is necessary. If 
only warm water is used, the arrowroot must be afterward boiled until it 
thickens. Sweeten with loaf sugar, and flavor with lemon peel or nut¬ 
meg, or add sherry, port wine, or brandy, if required. Boiling milk may 
be employed instead of water, but when this is done no wine must be 
added, as the milk would curdle. 


Cocoa Junket 9 



Cocoa 

1 teaspoonful 

50 calories 

Milk-sugar 

25 grams 

100 “ 

Milk, 5 oz. 

150 c.c. 

100 “ 

Junket tablet 

% 


Cold water 

1 oz. 



Dissolve the junket tablet in the water. Mix the cocoa and sugar, add 
the milk, and heat lukewarm, stirring constantly; add the dissolved junket 
tablet, stir thoroughly, and leave in a warm place to set. 


9 This and the following recipes were published in the American Journal of Medi¬ 
cal Sciences for January, 1912. 



INVALID’S DIETARY 


141 


Soft Custard 

Milk 

1 cup (8 oz.) 

160 calories 

Egg 

1 

80 “ 

Milk-sugar 

60 grams 

240 “ 

Salt 

a speck 


Vanilla 

2 to 3 drops 


Caramel, made 
of granulated 

sugar 

3 tablespoonfuls 

20 “ 


Beat the egg slightly; add the sugar, salt, and hot milk slowly. Cook 
in a double boiler, stirring constantly, until it thickens a little (if cooked 
too long the custard will curdle, but may become smooth again if set in 
a dish of cold water and beaten at once). Flavor and cool. 

To make caramel: put the sugar in a pan directly over heat and burn 
until a very dark brown. Dissolve in hot water or milk. 


Plain Junket or Rennet Custard 


Milk-sugar 

25 grams 

100 calories 

Milk 

5 oz. (150 c.c.) 

100 “ 

Junket tablet 

% 


Cold water 

1 oz. 


Vanilla 

few drops 


See directions for 

Cocoa Junket. 


Baked Custard 



Milk-sugar 

40 grams 

160 calories 

Milk 

6 oz. (180 c.c.) 

120 “ 

Egg 

1 

80 “ 

Nutmeg or 



vanilla 



Salt 

a speck 



Beat the egg slightly; warm the sugar and milk, stirring constantly; 
add to the egg, strain into a custard cup, and flavor. Bake in a pan of 
water in a moderate oven until a knife, when cut into it, will come out 
clean (% to 1 hour). 

Bread Pudding 


Milk-sugar 

45 grams 

180 calories 

Milk 

6 oz. (180 c.c.) 

120 “ 

Egg 

1 

80 “ 

Bread 

1 slice %" 



thick, 20 grams 

60 “ 

Butter 

y 2 oz. (15 grams) 

120 “ 


142 


NUTRITION AND DIETETICS 


Spread the bread with butter, and cut into squares. Beat the egg 
slightly; heat the milk and sugar, stirring constantly; mix with the egg 
and pour over the bread. Grate nutmeg over the top and bake the same 
as custard. 


Vanilla Ice Cream 



Cream 

4 oz. (120 c.c.) 

240 calories 

Milk 

2 oz. (60 c.c.) 

40 “ 

Milk-sugar 

60 grams 

240 “ 

Vanilla 

few drops 


Mix the cream, milk, and sugar and heat, stirring constantly, until 

the sugar is dissolved. 

Then flavor, cool, and freeze. 

Cocoa with Milk 



Cocoa 

1 rounding teaspoonful 

50 calories 

Milk-sugar 

60 grams 

240 “ 

Milk 

4 oz. (120 c.c.) 

80 “ 

Cream 

2 oz. (60 c.c.) 

120 “ 

Mix the sugar and 

cocoa; cook in the milk until dissolved. Serve 

with the cream. 



Cocoa 



Cocoa 

1 heaping teaspoonful 

50 calories 

Milk-sugar 

60 grams 

240 “ 

Water 

y 2 cup, 4 oz. 


Cream 

3 oz. (90 c.c.) 

180 “ 

Mix the cocoa and sugar, add the water, and boil for four or five min- 

utes. Then add the cream, or use less and serve 

with whipped cream. 

Coffee 



Milk-sugar 

60 grams 

200 calories 

Strong coffee . 

4-5 oz. 


Cream 

2 oz. (60 c.c.) 

120 “ 


Milk-sugar may be used likewise to sweeten tea, which may be served 
with or without cream. 

Lemonade 

Milk-sugar 120 grams 480 calories 

Cold water 7 oz. (210 c.c.) 

Lemon juice 2 tablespoonfuls 

(or to taste) 


PROPRIETARY POODS 


143 


Boil the sugar and water two minutes. Add lemon juice to taste, 
strain, and cool. The white of an egg may be added if desired. 

Orangeade 

Juice of 1-2 oranges 100-200 calories 

Milk-sugar, 50-100 grams 200-400 “ 

Mix the orange juice and sugar and-serve in a glass with cracked ice. 


PROPRIETARY FOODS 

A great variety of proprietary foods are manufactured. Practically 
all of them are made from common articles of diet, such as meat, eggs, 
milk, grain, etc. 

Proprietary foods possess no special nutritive virtues, as is so often 
claimed, which are not possessed by the natural foods from which they 
are manufactured. Neither do they possess any medicinal value unless 
some drug has been added to them. Some proprietary foods are partially 
digested. The predigested protein foods have an unusual and often dis¬ 
agreeable taste, and for this reason fail to stimulate the “appetite juice.” 
There is no evidence that predigested protein foods are more completely 
absorbed than natural foods. In fact, they are likely to cause digestive 
disturbances and diarrhea, as Yoit long ago pointed out. Some of them 
contain alcohol, as much as 22 per cent. If such a food is given as the sole 
or principal article of diet, the patient is likely to be kept in a state of 
constant exhilaration or intoxication. 

Carbohydrate proprietary foods are said to have been predigested 
when a portion or all of the starch has been converted into sugar (or 
sugars). They are neither more easily digested nor more completely ab¬ 
sorbed than the sugar (or sugars) into which the starch has been changed. 
The proprietary carbohydrate foods in general possess greater nutritive 
value than the protein foods. 

As Lusk has said, the chief value of proprietary foods lies in their 
t as te—and this is not always pleasing. Some proprietary foods may be 
useful at times in order to gratify a patient’s desire for change of flavor. 
Some are useful for modifying other foods, especially milk. Few, if 
any, of them should ever constitute the sole article of diet, except for 
the briefest periods or under exceptional circumstances. On account 
of their peculiar taste, or because of the lack of adaptation of the 
digestive glands (cf. Pavlov), it is always difficult to give proprietary 
foods in sufficient quantity to meet the energy requirements of the body 
without causing disturbances of digestion. Another, and more impor- 


144 


NUTRITION AND DIETETICS 


tant, fact is that the deficiency of vitamins in proprietary foods has been 
observed to produce serious disorders of metabolism, especially in 
children. 

The composition of various proprietary foods is given in the following 
tables: 


Analyses of Solid Meat Extracts* 


Name 

Per 

Cent 

Mois¬ 

ture 

Per 

Cent 

Total 

Ash 

Per 

Cent 

Chlorin 

as 

Sodium 
Chlorid 
in Ash 

Per 
Cent 
Total 
Pro¬ 
teins f 

Per 

Cent 

Total 

Meat 

Bases 

Armour’s Extract of Beef. 

21.66 

20.46 

5.47 

27.51 

9.52 

Beef Extract, Swift & Co. 

20.16 

27.28 

13.51 

15.38 

10.70 

Beef Extract, Coin Special, G. H. Ham¬ 






mond Co. 

12.39 

31.68 

13.25 

15.01 

13.14 

Extract of Beef, Premier, Libby, McNeill 






& Libby. 

21.86 

30.92 

18.32 

14.93 

9.98 

Liebig’s Extract of Meat. 

21.14 

21.03 

3.11 

30.50 

11.92 

“Rex” Brand Beef Extract, Cudahy Pack¬ 






ing Co. 

26.50 

24.06 

8.54 

22.12 

11.11 


* U. S. Dept, of Agriculture, Bureau of Chemistry, Bull. No. 114. 
f The sum of insoluble and coagulable proteins, proteoses, and peptones. 


Analyses of Fluid Meat Extracts* 


Name 

Per 

Cent 

Mois¬ 

ture 

Per 

Cent 

Total 

Ash 

Per 

Cent 

Chlorin 

as 

Sodium 
Chlorid 
in Ash 

Per 
Cent 
Total 
Pro¬ 
teins t 

Per 

Cent 

Total 

Meat 

Bases 

Beef Juice, Wyeth & Bro. 

Concentrated Fluid Extract of Beef, 

58.84 

16.21 

6.71 

6.45 

5.99 

Armour & Co. 

57.75 

17.23 

8.27 

6.76 

5.18 

Fluid Beef Jelly, Mosquera-Julia Food Co. 
Fluid Extract of Beef, Cibils Co., 

68.97 

13.85 

10.05 

8.13 

3.06 

Importers . 

64.63 

16.13 

11.38 

10.25 

4.24 

Meat Juice, Valentine’s Meat Juice Co... 
“Rex” Fluid Beef Extract, Cudahy Pack¬ 

57.64 

10.26 

1.77 

5.63 

6.05 

ing Co. 

55.99 

16.99 

8.48 

7.00 

8.21 

Vigoral, Armour & Co. 

49.94 

15.91 

7.02 

10.75 

6.30 


* U. S. Dept, of Agriculture, Bureau of Chemistry, Bull. No. 114. 
t The sum of insoluble and coagulable proteins, proteoses, and peptones. 


There are various other meat extracts on the market, but the average 
analyses of the different brands are so nearly alike that the various con¬ 
stituents will not differ markedly from the above figures. 



































PROPRIETARY FOODS 145 


Miscellaneous Preparations (Meat Extracts, Juices, and Powders)* 


Name 

Per 

Cent 

Water 

Per 

Cent 

Total 

Ash 

Per 

Cent 

Chlorin 

as 

Sodium 
Chlorid 
in Ash 

Per 
Cent 
Total 
Pro¬ 
teins t 

Per 

Cent 

Total 

Meat 

Bases 

Bouillon Capsules, Royal Specialty Co. . 

14.75 

39.75 

29.72 

22.19 

6.93 

Bovril, seasoned. 

43.39 

16.09 

8.73 

22.06 

6.02 

Beef Jelly, Mosquera-Julia Food Co. 

27.82 

17.31 

8.39 

28.63 

9.24 

Essence of Beef, Brand & Co. 

90.93 

1.34 

0.09 

5.07 

1.34 

Predigested Beef, H. K. Mulford Co. 

91.69 

0.18 

0.01 

1.19 

0.69 

Soluble Beef, Armour & Co. 

30.15 

14.55 

5.21 

37.76 

6.68 

Bovox Essence of Beef, The Bovox Co. . . 

65.77 

17.29 

9.73 

16.57 

2.78 

Johnson’s Fluid Beef . 

American Brand Extract of Beef, Ameri¬ 

47.22 

9.80 

4.37 

31.75 

3.87 

can Beef Extract Co. 

Bovinine Concentrated Beef, The Bovinine 

27.54 

34.73 

24.73 

26.69 

3.59 

Co. 

Essence of Mutton, The London Essence 

80.40 

1.55 

1.05 

14.14 

0.28 

Co . 

82.03 

2.25 

0.18 

12.00 

1.78 

Liquid Food, Murdock Liquid Food Co. .. 

86.09 

0.65 

0.20 

10.69 

0.25 

Maggi’s Bouillon. 

56.56 

21.94 

17.53 

2.13 

5.83 

Peptonized Beef, Rose. 

Beef Extract and Vegetable Tablets, 

45.13 

3.52 

1.63 

22.20 

9.89 

Armour & Co. 

22.29 

23.66 

18.14 

18.87 

3.15 

Leube-Rosenthal’s Beef Solution. 

Malted Meat Extract of Beef, American 

72.68 

3.91 

1.84 

16.13 

1.34 

Malted Meat Co. 

8.61 

7.87 

3.48 

9.82 

1.40 


* U. S. Dept, of Agriculture, Bureau of Chemistry, Bull. No. 114, 1908. 
f The sum of insoluble and coagulable proteins, proteoses, and peptones. 


The following table, giving the composition of meat juices prepared in 
the laboratory, illustrates the nutritive value of home-made as compared 
with commercial products. Bigelow and Cook 10 state that “meat juice 
prepared in the home or hospital ... is far superior as a food to the 
commercial meat extracts and so-called meat juices.” 


Meat Juices Prepared in Laboratory* 


Name 

Per 

Cent 

Water 

in 

Juice 

Per 

Cent 

Ash 

Per 

Cent 

Chlorin 

as 

Sodium 
Chlorid 
in Ash 

Per 

Cent 

In¬ 

soluble 

Pro¬ 

tein 

Per 

Cent 

Coagu¬ 

lable 

Pro¬ 

tein 

r? min n Kppt pnln nrPSSPfl... 

85.76 

1.53 

0.12 

1.00 

8.56 

T?niinrl hppf nrPSSfd at 60° C .. 

90.65 

1.36 

0.15 

4.25 

XIUU11U UuCl^ pi CooCU <X\j vv ^ ... 

Juice extracted from sirloin steak by cold 
. . 

96.13 

0.46 

0.05 

2.13 

Juice extracted from beef chuck by cold 
pressure after 6 hours at 60-100° C... . 

98.11 

0.39 

0.05 




* U. S. Dept, of Agriculture, Bureau of Chemistry, Bull. No. 114, 1908. 


» u. S. Dept, of Agriculture, Bureau of Chemistry, Bull. No. 114, 1908. 













































Analyses of Infants’ and Invalids’ Foods * 

From Sutherland's System of Diet and Dietetics (slightly modified) 


140 


NUTRITION AND DIETETICS 


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PROPRIETARY FOODS 


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• • •* rH 

r-P 04 CO 

a ^ co 

C3 t—I 04 
-m G4 
CO 

rv r 

. 03 03 

h 91 (O- 

P3 O O 

P -v> 


p 


vO 

CO 


od 

02 

Pd 

Pd 

p 

CD 

p 

p 

p 

o 

. 

>5 P 

p p 


a 

o 

V 

'HI 

o 

pd 

p 

a 

02 


o 

p 

V 


p 

or a 

8 aj 

v-> r5 

a ^ 

o . 

-• P 


CO 

H 

p 

p 

a 

o 


p 


p 

a 


• ~ ^ SH 

0> 02 
Pd Pd 
VO p p 

r^\ r^\ 


® X! 
P m 

Ph 

H 

P « 

* j§ 

O P7 
V > 
Pd 

pd 
P4 03 
Z) H 
’ 1—1 pd 
r P ®3 

^ a 


VH 

o 

Pd . 

02 p 

o u 
Pi p 

s g 

o 

Q § 


CO 


CO 


co P 
>a ® 

P-? V 
§ 8 
P r^J 
„ <H> 
ir 3 -v> 
O Cd 

p g 

p H 

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c» 

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pd 

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a ^ 

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s 

nd 
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p 

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a p 

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co 


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p 


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p 

p 

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co 

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^p 

a 


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m W 

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pi 


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04 


be 

P 


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f—I 

v 

P 

P 


P 


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p ro 
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a 


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t> 


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<?3 0) 


02 

02 


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s » 


co 

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"p 


^ s 

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w P ^ CO P 

a p w % 

P -1 * P i"- d 

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G4 

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05 

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0 

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04 

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tH 

tH 

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0 

04 

rH 

rH 

rH 

rH 

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rH 

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04 

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rH 

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00 

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CO 

co 

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vd 

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CO 

CO 

CO 

CO 

00 

rH 

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rH 

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CO 

GO 

0 

rH 

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rH 

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0 

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CO 

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t- 

tH 

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04 

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04 

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rH 

tH 

CO 

CO 

tH 

cd 

CO 

rH 

04 

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vd 

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rH 

rH 

cd 

tH 

00 

CO* 

vO 

00 

0 

rH* 

rH 

tH 

rH 


rH 



H 

rH 

04 

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rH 



rH 

rH 


tH 

tH 

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CO 

CO 

0 

t— 

O 

0 

O 

0 

GO 

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4h 

O 

04 

CO 

CO 

O 

04 

rH 

rH 

rH 

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rH 

05 

t' 

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CO 

rH 

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CO 

CO 

00 

CO 

00 

GO 

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cd 

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00 

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04 

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co 

.-rH r/3 
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p 
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^ l 

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p p 

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w 


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rrl ° 9 

p Ph ® 
^ HH 

kH P ^ 

M _Q 

co 

jaj w ^ 

.a ^ .22 

v >• > 
OOP 


P 

P 

P 

v 

o 


od "P 
o o 
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pH Ph 

r-t 04 

^ o o 
° Iz: Iz; 
Ph ^ ^ 


r^ O 

I H • rH 

• ri cc 

VH Hh 

^ P 

02 a 

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pd 

o 


p 

• rH 

H 'P 
P P 
Pi P 




p p 

pq w 

p p 

rP 05 

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hD 1-3 


Eh 

HH cj 

-m d 
02 P 
p be P 
3 p P 

'p^o 

CO 

Sp 

-S § p 

^ P P=! 
g rP p 
3 02 o 

vq Hi 


M 


nd 

o 

o 

Eh 

o 

02 


p 

s 


id 

o 

o 

Eh 


P 

p 

HI 

P 


P 

rP 

P 

P 


cd 

o 

o 

Eh 

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rs 

P 

• rH 

"o 


od 

o 

o 

Eh 


HI 

r^i 


Pd 

o 

o 

Eh 

CO 

rs 

8 ? 

12 

co 

O 


* Most of the analyses, except where otherwise stated, are those given by the makers 

































Analyses of Infants’ and Invalids’ Foods ( Continued) 


148 NUTRITION AND DIETETICS 





































proprietary foods 


149 


o 

vO 

o 


<4=1 

• pH 

d 

O 

a 

M 

• pH 

a 

<1 


«4H 

o 

m 

d 

P 

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a 

03 

bfl 

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£ 

03 

k 

«+H 

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03 

a 

o 


d 

d 

c3 

03 

03 

• rH 

P 

© 

<v 

Ph 




as b to w co co 

d o oq co h co 

© ©' © ©* cm cm’ 


^cococo'fcoooqooos 
<D aq os co co b- o a o io us 

rH © © GO* <M ©’ © ©’ rH CO © 


o 

CD 

b 

CD 


O 

vO 


OS 

cm 

d 


'CO 

GO 


03 

H 

O 

P 

03 


O 

b 

d 


o 

CM 

o’ 


CM O 00 
GO © CM 

CD CD CM 
vO 


as 

CD 

vd 

vo 


GO CD b 

CO b d 

• • • 

H H CD 

io t- cq 


>0 W O H OS 

CM OS rH CM CO 

CO* O b 03 

b lO 30 vO> 


vOvOvOvO©©vO©vO©© 
CO CO CO CD CO b b CO CO CO 00 

D 00 CO ri H 03 CO 6 >C CO Cq 

CM 30 rl b cq CO CO CD CM 


| 0.41 

2.00 

4.00 

3.60 


3.83 

3.20 

11.28 

0.64 

0.42 

0.35 

4.95 

0.65 

7.10 

1.35 

1.70 

© 

b 

© 

3.05 

1.30 

1.05 


o 

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o 

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00 

© 

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d 

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lO 

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d 

rH 

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CO) 

vO 

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rH 

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cm’ 


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d 

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d 



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rf 

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CD 

C3 

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O 

d 

d 

c3 

d 

o 

03 

d 

b 

c3 

rd 

CD 

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Ph 


d 
o 
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Ph 

i d 
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d o 

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n-j HH 

S’S 

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co d 
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■g 

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<1 o 


co 


d 
o 
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03 


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b o3 
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d to 3 

O H HH 


d 

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rP 


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P 03 

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d 


d 

03 

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d 

o 

o 

Ph 


d 


o o 

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Ph £ Ph 

„ ^ CO 

d Hd ^ 

b£lo 

d d «3 

.a g)-g 

b d rd 

H W O 


d 

o 
o 

Ph 

d 

03 
b 
c3 
CH 

£ A 

Pd £ 

03 O 

rs 

_d co 

PP PP 


This and the following analyses are taken from Wiley, Foods and Adulterations, Philadelphia, 1911. 





























150 


NUTRITION AND DIETETICS 



£~ 

GO 












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0> CDO 

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• 

03 

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CO 

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p2 

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C0O»0C0'^Q0 05'^C0i000 

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54) 


4ft 

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d & ^ 

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• •••••••••• 

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CO 


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fa 


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V) 

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o 

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ft 


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■73 *+h 

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P -a 
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03 £ 
ft c/3 
0) 

nd bfi 

• rH • rH 

p "O 

CP oj 

• rH H 

H Ph 


<03 

ft3 


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P 

O 

-M 

ft 

03 O 
ft p 

43 % 
03 

ft 
'o P3 
03 ”3 

P O' 

• rH • rH 
£ ^ 

QJ 

• rH • rH 

u t* 
+-> +-> 

£ ^ 


P 

c3 


a> 


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o 

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00 


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2 qe *a p % 


» 




* Journal of the American Medical Association, xlviii, 1612, 1907. 

t Total calories per diem dose includes the calories of alcohol in the liquid medicinal foods and the calories of the fat in milk. 







































REFERENCES 


151 


REFERENCES 

Atwater. Farmers’ Bull., 142, U. S. Dep. Agric. 

Atwater and Bryant. U. S. Dep. Agric. Bull., 28, rev. ed. 

Aufrecht and Simon. Deutsche med. Wchnschr., xxxiv, 2308, 1908. 
Bahrdt. Jahrb. f. Kinderh., lxxi, 249, 1910. 

Bailey. Bull. 240, Conn. Agric. Expt. Sta. 

Bassler. N. Y. Med. Journ., xcii, 557, 1910. 

Benedict. Ibid., 527, 1907. 

Benedict and Suranyi. Ztscbr. f. klin. Med., xlix, 502, 1903. 
Blatherwick. Arch. Int. Med., xiv, 409, 1914. 

Block. Journ. Hyg., Cambridge, xix, 283, 1921. 

Boyd. System Diet and Dietetics, Sutherland, 283, 1908. 

Brown. Brit. Med. Journ., i, 872, 1911. 

Brugsch. Diat. inn. Erkrank, Berlin, 1911. 

Chick and Hume. Proc. Roy. Soc. London, B, xc, 60, 1917. 

Chittenden. Brit. Med. Journ., ii, 1100, 1906; ii, 656, 1911. 
Chudnowsky. See Atwater and Langworthy, Digest of Metabolism Ex¬ 
periments, U. S. Dep. Agric. Bull. No. 45, 181, 1897. 

Cohen and Mendel. Journ. Biol. Chem., xxxv, 425, 1918. 

Coleman and Du Bois. Arch. Int. Med., xiv, 168, 1914; xv, 887, 1915. 
Coleman and Gephart. Ibid., xv, 882, 1915. 

Czerny and Keller. Metabolism and Practical Medicine, von Noorden, 
iii, 861, 1907. 

Czerny and Steinitz. Ibid. 

Dapper. Diss. Marburg, 1902. 

Drummond. Biochem. Journ., xiv, 660, 1920. 

-Journ. Physiol., Iii, 95, 1918. 

Du Bois. Arch. Int. Med., x, 177, 1912; xvii, 887, 1916. 

Du Bois, D. and Du Bois, E. E. Arch. Int. Med., xvii, part 2, 863, 1916. 
Eijkman. Arch. Hyg., lviii, 150, 1906. 

Freund. Ergebn. d. inn. Med. u. Kinderh., iii, 139, 1909. 

Funk. Journ. Physiol., xiv, 75, 1912. 

Gauthier. Quoted from Howell. Text-book of Physiology, 1911. 
Grafe. Deutsches Arch. f. klin. Med., cvi, 328, 1914. 

Graham and Poulton. Quart. Journ. Med., vi, 82, 1912. 

Grindley. U. S. Dep. Agric. Bull., 141. 

Halberstadt. Arch. f. Kinderh., lv, 1911. 

Hall. Purin Bodies of Foodstuffs, London, 1903. 

Hart, Steenbock and Smith. Journ. Biol. Chem., xxxviii, 305, 1919. 
Henderson. Harvey Lect., 1914-1915. 

Hesse. Med. Klinik, vi, 626, 1910. 

-Scurvy, Past and Present, 1920. 



152 


NUTRITION AND DIETETICS 


Hesse. Journ. Am. Med. Ass., lxix, 1583, 1917; lxxiv, 217, 1920. 
Heubner. Berl. klin. Wchnschr., 449, 1901. 

Hill and Flack. Brit. Med. Journ., i, 1068, 1310, 1911; ii, 597, 1911. 
Hoesslin. Virchow’s Arch. f. path. Anat., lxxxix, 95, 1882. 

Holst and Frohlich, Z. Hyg. Infektronsh., lxxv, 334, 1913. 

Hopkins. Journ. Physiol., xliv, 425, 1912. 

Karr. Journ. Biol. Chem., xliv, 277, 1920. 

Kocher. Deutsches Arch. f. klin. Med., cxv, 82, 1914. 

Krehl. The Principles of Clinical Pathology, Philadelphia. 

Krug. Von Noorden’s Beitr. z. Lehre v. Stoffwechsel, ii, 83, 1894. 
Labbe. La Diathese Urique, Paris, 1908. 

Landergren. Skandin. Arch. f. Physiol., xiv, 112, 1903. 

Langworthy. Farmers’ Bull., 128, U. S. Dep. Agric. 

Leube. Sitzungsb. d. phys.-med. Gesellsch. zu. Wiirzb., 5, 1905. 

Leva. Arch. f. Verdaungsk., xvi, 267, 1910. 

Leyden and Klemperer. Von Leyden’s Handb. d. Ernahrungstherapie, 
ii, 345, 1904. 

Linser and Schmid. Deutsches Arch. f. klin. Med., lxxix, 514, 1904. 
Lusk. Science of Nutrition, 1906. 

Magnus-Levy. Von Noorden’s Metabolism and Practical Medicine, 
1907. 

-Johns Hopkins Hosp. Bull., xxii, 46, 1911. 

May. Ztschr. f. Biol., xxx, 1, 1894. 

McCay. Scientific Memoirs by Officers of the Gov. of India, new series, 
Nos. 34, 37. 

McCollum and Davis. Journ. Biol. Chem., xv, 167, 1913. 

McCollum and Kennedy. Ibid., 24, 491, 1916. 

McCollum, Simmonds and Parsons. Ibid., xlvii, 111, 1921. 

McCollum, Simmonds, Shipley and Park. Ibid., 1, 5, 1922. 

Mills. Arch. Int. Med., vii, 694, 1911. 

Muller. Von Leyden’s Handb. d. Ernahrungstherapie, i, 213, 1904. 

Nash and Benedict. Journ. Biol. Chem., xlviii, 463, 1921. 

Noorden, von. Metabolism and Practical Medicine, ii, 7, 73, 1907. 
Osborne and Mendel. Science, xxxiv, 722, 1911. 

- See Mendel. Harvey Lect., 1914-1915. 

-Carnegie Inst. Wash. Publication No. 156, Parts 1, 2. 

-Journ. Biol. Chem., xv, 311, 1913; xvi, 423, 1913-1914. 

Pavlov. The Work of the Digestive Glands, 2d English ed., 1910. 
Penzoldt. Deutsches Arch. f. klin. Med., Ii, 535, 1893. 

Rolland. Ibid., cvii, 440, 1912. 

Rubner. Gesetz d. Energieverbrauchs, 1902. 

-Von Leyden’s Handb. d. Ernahrungstherapie, i, 44, 1903. 

Schaffer and Coleman. Arch. Int. Med., iv, 538, 1909. 

Schmidt and Bessau. Therap. Monatsh., 116, 1910. 







REFERENCES 


153 


Senator and Richter. Ztschr. f. klin. Med., liv, 16, 1904. 

Snyder. IJ. S. Dep. Agric. Bull., 43. 

Snyder and Voorhees. Ibid., 67. 

Steinitz. Jahrb. f. Kinderh., lvii, 689. 

Strauss. Pract. Winke. f. die chlorarme Ernahrung, Berlin, 1910. 
Svenson. Ztschr. f. klin. Med., xliii, 86, 1901. 

Torrey. Journ. Infect. Dis., xv, 72, 1915. 

Tungendreich. Deutsche med. Wchnschr., xxxv, 2319, 1909. 

Umber. Lehrb. d. Ernahr. u. Stoffwechsel., 1909. 

Vogel. Miinchen. med. Wchnschr., cvii, 2433, 1911. 

Voit. Quoted by Lusk. Science of Nutrition, 98, 1906. 

Widal. Verhandl. d. Kong., f. innere. Med., xxvi, 43, Wiesbaden, 1909. 
Woods and Snyder. U. S. Dep. Agric., Farmers’ Bull., 249. 


CHAPTER III 


PRINCIPLES OF TOXICOLOGY 
Frank P. Underhill 

Toxicology. —Toxicology is the science of poisons. In its broadest 
use it is the science that treats of the origin, nature, properties, effects and 
detection of poisons, and it includes treatment of poisoning. The science 
falls naturally into two divisions: (1) that dealing with the effects of 
poisons; (2) that relating to the chemical identification and isolation of 
poisons. From these divisions it is readily seen that the first relates more 
especially to physiological action, whereas the latter is primarily concerned 
with chemical reactions. 

To give a general satisfactory definition of a poison is a somewhat 
difficult feat. Nevertheless various attempts have been made, examples of 
which follow: 

Husemann: “We define poisons as such inorganic or organic sub¬ 

stances as are in part capable of artificial preparation, in part existing, 
ready formed, in the animal or vegetable kingdom, which, without being 
able to reproduce themselves, through the chemical nature of their mole¬ 
cules under certain conditions, change in the healthy organism the form 
and general relationship of the organic parts, and through annihilation of 
organs, or destruction of their functions, injure health, or, under certain 
conditions, destroy life.” 

Robert: “Poisons are organic or inorganic unorganized substances 
originating in the organism itself, or introduced into the organism, either 
artificially prepared, or ready formed in nature, which through their 
chemical properties, under certain conditions, so influence the organs of 
living beings that the health of these beings is seriously influenced tem¬ 
porarily or permanently.” 

Blyth: “A substance may be called a poison if it is capable of being 
taken into any living organism, and causes, by its own inherent chemical 
nature, impairment or destruction of function.” 

154 


CONDITIONS MODIFYING EFFECTS OF POISONS 155 

Sollmann: poison is any substance which, acting directly through 

its inherent chemic properties, and by its ordinary action, is capable of 
destroying life, or of seriously endangering health, when it is applied to 
the body, externally, or in moderate doses (to 50 gm.) internally.” 

CLASSIFICATION OF POISONS 

There are at least two ways in which poisons may be classified: (1) ac¬ 
cording to their chemical properties; (2) according to their physiological 
effects. From a scientific viewpoint neither system nor a combination is 
entirely adequate and one must either omit all attempts at classification 
or else be content to classify poisons from the standpoint of practical 
utility only. A chemical classification follows: 

1. Acids and alkalis. 4. Alkaloids. 

2. Metallic poisons. 5. Volatile organic poisons. 

3. Gaseous poisons. 6. Miscellaneous poisons. 

The physiological classification recognizes the most prominent symp¬ 
toms as the basis for division of poisons. According to this classification, 
which is that adopted and defined by Sollmann, poisons may be divided 
into three great groups: 

1. Irritants. —-These produce inflammation; if they are taken by the 
mouth, there is pain throughout the alimentary canal, vomiting, purging, 
delirium, coma. So many poisons are to some extent irritant that these 
symptoms are very commonly present. The irritants can be divided into 
corrosives , which produce destruction of tissue, and simple irritants , which 
do not destroy tissue. If corrosives are taken by the stomach, the vomit 
is often bloody. 

2. Nerve Poisons. —These act on the neuromuscular apparatus, and 
include most of the poisons which are fatal in minute doses. They are 
subdivided into convulsants which cause spasms, somnifacients which 
cause sleep and coma, and cardiac poisons which stop the heart. 

3. Blood Poisons. —These poisons alter the hemoglobin or blood- 
corpuscles. These include the toxic gases, nitrites, etc. Their action is 
generally characterized by cyanosis. 

CONDITIONS MODIFYING EFFECTS OF POISONS 

The influence of a poison upon the organism is very materially modi¬ 
fied by a variety of conditions. In general these may be divided into two 
great classes: (1) those relating to the poison itself and the manner of 
its administration; (2) those relating to the organism itself. 


156 


PRINCIPLES OF TOXICOLOGY 


Poison and Methods of Administration 

Physical State or Form of a Poison. —The physical state of a poison 
has a marked influence in modifying its action. Thus a poison is more 
rapidly absorbed in a gaseous form than in a solid or even a liquid state. 
In order that a substance may act as a poison it must be capable of solu¬ 
tion, and absorption by the blood. No substance completely insoluble can 
be regarded as a true poison. Barium chlorid, which is readily soluble, 
must be regarded as extremely toxic, whereas the insoluble barium sulphate 
is devoid of toxic properties. In fact advantage is taken of this in the 
employment of barium sulphate in X-ray photography in diagnosis of 
gastro-intestinal disorders. The principle of the form of poison modifying 
its action is made use of in the treatment of various types of intoxication 
by means of antidotes, the object aimed at being to change the soluble 
substance to one insoluble and hence incapable of absorption. 

In general, dilution of a poison tends to favor rapid absorption and 
this in turn hastens and intensifies the toxic effect. An exception to this 
rule is seen in the case of those poisons with a corrosive action. These 
have their detrimental influence greatly decreased by dilution. Poisons 
taken into the stomach in the form of a dry powder may not manifest toxic 
symptoms for hours after administration. Usually the larger the dose the 
more rapid and severe are the effects. This, however, is not always true. 
Thus arsenic in large doses may act as an irritant to the stomach, causing 
vomiting, with prompt ejection of the poison so that few or no toxic symp¬ 
toms result. On the other hand a very much smaller dose, being devoid 
of irritant action on the stomach, allows absorption of the poison with 
subsequent symptoms which may terminate fatally. Again the solvent 
containing the poison exerts a marked effect upon its action. Thus of 
alcoholic, aqueous or oily solutions, the first is most rapidly absorbed, the 
last least so and, in consequence, more prompt and emphatic effects are 
to be expected the more rapid the absorption. Hot solutions are usually 
absorbed more rapidly than cold. 

Path of Absorption. —In general a poison exerts its specific action 
irrespective of the mode of administration. In other words, it makes 
little difference through which path the poison reaches the circulation. 
The only modifying influence exerted by changing the path of absorption is 
the time of appearance of symptoms which varies directly with the rate 
of absorption. Thus symptoms appear most rapidly when poisons are in¬ 
jected directly into the blood-stream. Intraperitoneal and intramuscular 
injection stand next in order followed by subcutaneous and intradermal 
injection. 

Poisons are less rapidly absorbed when taken by mouth. The condi- 


CONDITIONS MODIFYING EFFECTS OF POISONS 157 

tion of the stomach greatly modifies the rate of absorption. A diseased 
stomach may markedly -delay the absorption of a poison or, on the other 
hand, prove highly susceptible to an irritant poison. Food in the stomach 
may delay absorption either by retarding the emptying of this organ or 
by changing temporarily the physical state of the poison. Many apparent 
anomalies of the effects of poisons may he explained in this manner. 
Although it may be generally accepted that the path of absorption modifies 
the action of a poison only in its time relations and does not alter its 
specific effect, yet there are notable exceptions, for in certain instances the 
mode of administration materially alters the action of the poison. This 
is particularly true of substances resembling proteins, hence capable of 
alteration by the digestive enzymes. Snake venom by mouth is entirely 
harmless even though highly poisonous when it gains direct entrance 
to the blood. The same is true of the toxic proteins, ricin and abrin, and 
various bacterial toxins fall into the same class. 

Poison - and Its Delation to the Organism 

The most important conditions residing in the organism that modify 
the action of poisons are (1) age, (2) idiosyncrasy, (3) habit, (4) tol¬ 
erance, (5) physical state of the individual. 

Age. —As might be assumed, the age of an individual distinctly modi¬ 
fies susceptibility to poison. Although as a rule the younger the in¬ 
dividual the greater the susceptibility, there are many notable exceptions. 
Thus, for example, children are relatively less susceptible to the action of 
strychnin, belladonna, and calomel. Conversely, young children are par¬ 
ticularly susceptible to the action of opium and its constituents and the 
same may be said of the other narcotic drugs. In old age poisons may 
react with unusual severity indicating a reduced resistance. 

Idiosyncrasy. —The term idiosyncrasy is applied when an individual 
exhibits peculiar, unusual reactions to certain poisons. Lack of knowl¬ 
edge of this peculiar personal susceptibility or tolerance may result in 
serious disturbances in bodily function or even terminate in death. In a 
given case of poisoning, the possibility of this distinctive characteristic 
should always be taken into consideration. Idiosyncrasy may be mani¬ 
fested toward a large number of substances, some of which are ordinarily 
non-toxic, so that this unusual sensitiveness may be both qualitative and 
quantitative. This feature is brought into prominence in different in¬ 
dividuals especially by morphin, calomel, arsenic, mercury, antipyrin, 
cocain, etc. 

On the other hand, in some individuals a drug will induce an effect 
exactly opposite to that usually produced. Thus morphin will cause wake¬ 
fulness instead of sleep, or in larger doses convulsions simulating those 


158 


PRINCIPLES OF TOXICOLOGY 


of strychnin. Many individuals react with severe symptoms after eating 
or smelling of a large variety of substances, such as lobsters and other 
shellfish, honey, various fish, eggs, mutton, strawberries, sewer gas, musk, 
smell of animals, and odor of flowers. 

Habit. —Repeated small doses of a poison generally lessen the effect. 
By gradually increasing the initial small dose of a poison relatively large 
doses may be taken without evidence of toxic symptoms. Habitual mor- 
phin users are pertinent examples, very large doses being necessary finally 
to produce the desired effect. Again, in certain parts of Europe arsenic 
eating is notorious, huge quantities being taken daily. Whether in the 
case of morphin the organism develops an ability to oxidize the drug to 
an unusual degree or whether the intestine acquires a resistance to absorp¬ 
tion remains indecisive at present. So far as arsenic is concerned the 
assumption has been made for many years that there was a gradually 
increasing resistance to its effects. Very recently, however, it has been 
shown that the apparent habituation to arsenic may perhaps, in part at 
least, be ascribed to the quality of the arsenic consumed. Thus when 
arsenic made up of small crystals, or powdered, was ingested, much 
smaller doses were needed to produce toxic effects than when larger par¬ 
ticles were introduced. From this it would appear that the whole matter 
may be explained on the basis of solubility of the arsenic, the powder or 
small crystals being much more readily soluble, hence more rapidly ab¬ 
sorbed, than the larger, coarser, crystals. 

This tolerance to poisons acquired through habit is not absolute, since 
generally toxic effects and even death may be induced by slightly exceed¬ 
ing the limit of habituation. It is this fact that largely explains the 
death of the habitue of morphin and of other similar poisons. Habit, 
however, cannot be acquired with all drugs, for antimony or mercury, for 
example, cannot be taken long with impunity even in relatively small 
doses. 

Tolerance. —Certain individuals exhibit a very noteworthy resistance 
to the action of certain poisons. This resistance or tolerance is natural, 
not having been acquired by habituation, but it is rarely absolute so that 
it can hardly be regarded as a natural immunity. Thus some persons are 
capable of taking large doses of morphin without any apparent effect. 
The explanation of this peculiarity is not clear. In some instances it 
may be due either to non-absorption, rapid elimination, unusual ability 
to neutralize or destroy the poison or to anatomic peculiarities. In some 
instances none of these hypotheses seems to hold. 

Disease. —Pathological conditions in the body may very naturally 
influence the action and effects of poisons. This modified action may be 
manifested as an increased susceptibility or the effect may be greatly 
diminished. Those conditions that influence absorption and excretion play 
a particular role in this respect. Renal disease, for example, increases 


SYMPTOMATOLOGY OF POISONS 


159 


the susceptibility to arsenic and other drugs. In paralysis, strychnin acts 
less readily. In peritonitis, delirium tremens, and in those states where 
intense pain exists, the power of morphin is diminished, whereas in con¬ 
ditions primarily associated with the nervous system, as in inflammatory 
conditions of the brain, an increased susceptibility may be noted. In in¬ 
sanity with maniacal characteristics and in convulsions, narcotics may be 
almost without influence. Exhaustion tends to increase susceptibility. 
General reduction of vitality from whatever cause usually means a lowered 
resistance to poisons. On the other hand, sleep, perhaps owing to lessened 
functional activity, has a tendency to diminish or at least to retard the 
action of poisons. 

FATE OF POISONS 

After absorption poisons rapidly leave the blood unless indeed they 
combine with the constituents of the blood and change its characteristics 
either temporarily or permanently. In general, however, poisons remain 
in the blood for a comparatively short time, being excreted through the 
urine, saliva, bile, sweat and feces. In certain instances more of the 
poison is eliminated by the feces than by the urine, lead, for example. 
Usually, however, most of the poison passes by way of the renal path. 
Poisons are promptly eliminated from the body but are deposited in all 
the principal organs and tissues. In general the liver contains the greater 
amount of stored poison, the amount deposited in the other organs vary¬ 
ing with the type of poison. Gaseous poisons are not deposited but are 
promptly excreted by the lungs. 

So far as one may judge, a poison deposited in an organ enters into 
some chemical combination with the cellular constituents and while 
thus deposited may be regarded as without special detrimental effect. 
Gradually this combination disrupts and the poison is thrown into the 
general circulation, injuring sensitive tissues in its passage to the ex¬ 
cretory organs which, indeed, may suffer injury sufficient to cause death. 
Usually inorganic poisons are eliminated from the body unchanged, the 
organism being unable to alter them. On the other hand, the natural 
response of the body is to change or modify the poison prior to elimina¬ 
tion. Most of the organic poisons are altered in passage through the 
body by combination with constituents of the body or by undergoing 
oxidation, hydrolysis or other similar transformation. 


SYMPTOMATOLOGY OF POISONS 

There are certain outstanding features in poisoning that may be of 
value to the physician in diagnosis. These symptoms are general and, 
although they do not indicate specific poisons, their presence or absence 


160 


PRINCIPLES OF TOXICOLOGY 


excludes certain possibilities. Special symptoms relating to specific poisons 
will be considered under individual poisons. 

Nausea, Vomiting and Purging. —When these suddenly appear in a 
normal individual, it is indicative of the presence of a gastro-intestinal 
irritant or of the onset of some acute disease. Many poisons, especially 
metals and food poisons, are characterized by initial symptoms of nausea, 
vomiting and purging. If the history of the case agrees with the pos¬ 
sibility of poisoning, measures should be taken at once to assist the body 
in its efforts to rid itself of the noxious substances. 

Vasomotor Disturbances. —The effects of poisons upon the vasomotor 
centers is indicated by the fact that many poisons lead to marked changes 
in the skin. The color may be pale or the natural color may be much in¬ 
tensified and urticarial rashes are common. Heart action and respiration 
may be markedly modified in either direction. 

Cerebral Symptoms. —The influence of poisons upon the cerebrum 
lead to stupor or coma, or may produce convulsions, illusions or hallucina¬ 
tions. Thus, hallucinations and temporary delusions may follow the use 
of salicylic acid and strychnin may cause convulsions. Stupor and coma 
may be induced by narcotics or may be due to alcoholism or cerebral 
hemorrhage. 

Temperature. —The temperature changes in poisoning have not been 
sufficiently studied to make definite statements concerning them. Certain 
it is that usually changes in temperature must be regarded as secondary 
effects rather than specific effects of poison. Some poisons, like cocain 
in large doses, may elevate temperature, but usually in poisoning the 
temperature is either normal or is low, in some instances being as low as 
95° F. 

Pulse.— Generally in acute poisoning the pulse is quick and feeble, 
the extent to which this is true being determined by the degree of shock 
that may be present. Poisons that have a specific action upon the respira¬ 
tory center may influence the pulse only slightly, if at all, and the pulse 
may continue with a good tone for some time after respiration has ceased. 

Respiration.— The most common effect of poisons on the respiration 
manifests itself in dyspnea, which may be due to mechanical obstruction, 
as in edema of the glottis from local action of a corrosive poison, or to 
paralysis, as in chronic lead poisoning, or to muscular spasm, as in poison¬ 
ing with strychnin, or to direct action on the respiratory center, as may 
be observed with some poisons of bacterial origin. Cheyne-Stokes respira¬ 
tion marks the approaching termination of many cases of fatal poisoning. 

Motor Disturbances. —Motor disturbances are so characteristic in 
certain instances that they lead at once to a correct diagnosis. In lead 
poisoning the wrist-drop is sufficient to arouse suspicion; tetanus due to 
strychnin poisoning is quite peculiar and the mydriasis of atropin poison¬ 
ing is characteristic. Retention of urine occurs with narcotic poisons, 


DIAGNOSIS OF POISONING 


161 


although a general reaction of fatal poisoning is paralysis of sphincters. 
This fact tends to complicate diagnosis. 

The Eye. —Only a few reactions upon the eye are of particular value. 
Thus contraction of the pupil by morphin and dilatation by atropin are 
quite characteristic. Yellow vision with santonin and blindness from 
wood alcohol poisoning are quite specific. 

The Ear. —Quinin causes a ringing sensation in the ear, the hearing 
is more acute under the influence of strychnin and salicylic acid causes a 
buzzing sensation. 

Modified Sensations. —Various changes of sensation in the skin, such 
as anesthesia, hyperesthesia, pins and needles sensation, etc., probably have 
their origin in some form of poisoning. Neuritis from lead, arsenic and 
alcohol furnishes examples of abnormalities of sensation induced by 
intoxication. 

Skin Lesions. —The long-continued use of bromids or iodids may 
result in acnes or fungoid sores. Chronic arsenic poisoning gives rise to 
the peculiar coloring of the skin called arsenic melanosis, and silver causes 
the coloration known as argyria. Gangrene may be induced by ergot and 
members of the arsphenamine group may be responsible for varied skin 
eruptions partaking of the nature of urticarial, scarlatinoid and morbili- 
form erythemas together with itching or pruritus of the skin. 


DIAGNOSIS OF POISONING 

At times the diagnosis of poisoning is exceedingly difficult, since 
with a few notable exceptions the effects of poisons are not characteristic. 
It is, of course, of the utmost importance to be able to make a diagnosis 
of poisoning so that proper treatment may be instituted. 

Suspicion of poisoning arises if an individual who has previously 
been in apparent good health suddenly manifests notable pathological symp¬ 
toms which rapidly become intensified. This suspicion is strengthened 
if the symptoms appear a short time subsequent to the ingestion of some 
food or drink which may have had a peculiar odor or taste. Suspicion 
is further firmly established if the symptoms agree closely with those 
characteristic of a certain group of poisons and if they can be differentiated 
from disease. 

In general, the physician is guided only by symptomatic evidence. 
This may entirely mislead him, since a variety of diseases may cause 
symptoms simulating those induced by poisons. Thus, irritant poison¬ 
ing may be simulated by gastro-enteritis, gastric and intestinal ulcers, 
acute indigestion, appendicitis, intestinal obstruction, peritonitis, etc. On 
the other hand, narcotic poisoning may be simulated by epilepsy, apoplexy, 
cerebral hemorrhage, certain heart diseases, inflammation of the cerebro- 


162 


PRINCIPLES OF TOXICOLOGY 


spinal system, uremia, etc. The symptoms of arsenic poisoning and those 
of cholera morbus are very similar. One may readily mistake apoplexy 
or uremia for opium poisoning. The resemblance between the symptoms 
of strychnin poisoning and tetanus is very close. 

In acute poisoning a careful examination will many times enable the 
physician to make an immediate accurate diagnosis. Evidences of cor¬ 
rosion on the lips, tongue, mouth and throat lead one to suspect that a 
corrosive poison has been taken. Chloroform, carbolic acid, potassium 
cyanid and other odoriferous substances may be detected on the breath, 
and examination of the vomitus and even of the feces may reveal important 
evidence. The urine is of considerable importance in examinations of 
this kind. 

The long-continued use of sulphonal or trional gives the urine a red 
color from the presence of hematoporphyrin which may he identified by 
the spectroscope. Methylene-blue imparts a green color to the urine, 
and antipyrin and fuchsin cause it to assume a red hue. In santonin 
poisoning the fresh urine is normal in color but upon being made alkaline 
turns bright red. The urine turns dark green with phenol and cresol, 
the color deepening on standing. Quinin may cause hemoglobinuria which 
also results from the inhalation of arseniurated hydrogen. Potassium 
chlorate induces methemoglobin, and blood in the urine may follow the 
administration of any genito-urinary irritant such as cantharides or tur¬ 
pentine. Phosphorus, mercury or lead may give the urine a brown or 
greenish brown color. 

Chronic poisoning is even more difficult to diagnose than acute poison¬ 
ing, because the symptoms are usually not sufficiently definite to arouse 
the suspicions of the physician. 

There are no definite rules to establish a diagnosis of poisoning dur¬ 
ing life except by chemical analysis of some of the excretions of the body, 
such as urine, feces or vomitus. Any drink, food or medicine suspected 
should he subjected to analysis also. In no other way is it possible abso¬ 
lutely to differentiate between the symptoms caused by disease and those 
induced by poisons. 


TREATMENT OF POISONING 

Each type of poisoning requires specific treatment. In many in¬ 
stances, however, the poison taken is unknown and it is therefore essential 
that general rules of treatment be established. These are: (1) removal 
of the poison; (2) administration of antidotes; (3) symptomatic treatment. 

Removal of Poison. —The measures taken will depend upon the site 
to which the poison was applied. If the skin or mucous membranes are 
concerned, the best agent for removal of the poison is water copiously 


TREATMENT OF POISONING 


163 


applied. This application not only dilutes the irritant agent but washes 
the site free from it. If the poison is not freely soluble in water (for 
instance, carbolic acid), alcohol may be employed. Chemical antidotes 
may he added to wash-water—thus for acids, soaps or liniment calcis; 
for alkalis, lemon juice or vinegar. It should be pointed out that strong 
acids or alkalis should never he used in the treatment of irritant poisons. 
After the site has been thoroughly freed from the toxic agent it should 
be covered with a bland oil or salve. 

Most poisons are taken by mouth, hence, in treatment, the stomach 
should be emptied as soon as possible unless indeed sufficient time has 
elapsed to make this procedure useless. On the other hand, it is always 
a good plan to follow, since the cleansing of the stomach aids greatly in 
most cases of poisoning. There are only a few instances of poisoning 
where emptying the alimentary tract is contra-indicated. The most notable 
of these is in strychnin poisoning and in extensive corrosion of the ali¬ 
mentary canal. In emptying the stomach two types of procedure may he 
followed: the administration of emetics and lavage. Emetics are most 
easily given and have the advantage of not causing struggling on the part 
of the patient. If possible, however, lavage, employing the stomach tube, 
either through the mouth or nose, is to be preferred since it cleanses the 
stomach more thoroughly and also permits the introduction of chemical 
antidotes. Moreover, it is less depressing to the patient and must he 
employed when poisons have been taken that inhibit the vomiting center— 
for example, chloral or morphin. 

If emetics are administered repetition should be practiced at intervals 
of from 15 to 30 minutes if necessary. Apomorphin (5 mg. [grain 
1/10] in 1 per cent solution = 5 c.c.) subcutaneously is very rapid and 
effective in its action but has a distinctly depressing influence. Its great 
advantage lies in the fact that it is the only emetic that can be given 
hypodermically and it is particularly useful when resistance to treatment is 
offered. Copper sulphate or zinc sulphate are safe and efficient emetics. 
Copper sulphate is perhaps more effective than zinc sulphate but it is 
also more irritant. Both produce a minimum of depression. They should 
not be employed when irritant poisoning is under treatment. The dose 
of zinc sulphate is 2 grams in a glass of water; for copper y 2 gram at 
once, or three doses of 0.3 gram fifteen minutes apart. If vomiting does 
not occur, the copper salt should be removed by lavage. In emergencies 
a dessertspoonful of ground mustard stirred in a cup of tepid water may 
serve as an efficient emetic. At times it is desirable that the entire ali¬ 
mentary tract be cleansed and for this purpose cathartics should be em¬ 
ployed. They need not be given, however, until the most acute symptoms 
have subsided. The saline cathartics are to be recommended for this 
purpose; oily cathartics in general should be avoided. Enemas are of 
little value. 


164 


PRINCIPLES OF TOXICOLOGY 


Administration of Antidotes. —An antidote neutralizes the action 
of a poison either by changing its physical state or its chemical composi¬ 
tion, thereby preventing its action or retarding its absorption. Since the 
compounds formed by administration of antidotes may he only slightly less 
toxic than the original poison or may become poisonous by remaining in 
the stomach, the giving of antidotes should be combined with lavage or 
the administration of emetics. If lavage is practiced, the antidotes may 
he added to the wash-water; if emetics are used, antidotes may be ad¬ 
ministered between the intervals of vomiting. In general antidotes should 
be given repeatedly at short intervals. In the selection of an antidote care 
should be exercised that it be as harmless as possible and that the substance 
resulting from its action is practically inert, at least temporarily. 

Some antidotes, like raw eggs, acacia, milk, boiled starch or flour, which 
may be given in quantities as desired, act either by combining with the 
poison to form an insoluble compound—for example, eggs in the case of 
metals, especially mercury—or by enveloping the poison temporarily in an 
impenetrable membrane, hence lessening absorption, accomplished in part 
by delaying the exit from the stomach. In the case of irritant poisons 
these antidotes also tend to allay inflammation. 

One of the most valuable antidotes is tannin which acts as a precipitat¬ 
ing agent. This may be employed in the form of very strong hot tea 
which may be given ad libitum. Alcohol diminishes its efficiency since 
the precipitates formed are, for the most part, soluble in alcohol. The 
following antidotes will be found useful against specific poisons: Alkaloidal 
poisons —fifteen drops of tincture of iodin in half a glass of water. 
Barium —either sodium sulphate (Glauber’s salt) or magnesium sulphate 
(Epsom salt). Oxalates —calcium, either in the form of chalk, limewater, 
or whiting. Phosphorus —copper sulphate or old turpentine. Acids — 
weak alkalis, such as chalk, baking soda, soap, burnt magnesia. Alkalis — 
weak acids, such as vinegar or lemon juice. Alkaloids , glucosids and 
phosphorus —antidotes for these poisons are oxidizing agents which tend 
to oxidize and hence to nullify the action of the poison. Potassium per¬ 
manganate, about two grains of the crystals in a glass of water, repeatedly 
given if vomiting occurs or at least a liter of a 0.05 per cent solution. 
In no case should any undissolved crystals be administered. For hydro¬ 
cyanic acid poisoning potassium permanganate, hydrogen peroxid or 
sodium thiosulphate may be employed. 

In treatment of poisoning the hypodermic administration of anti¬ 
dotes is sometimes useful; thus for hydrocyanic poisoning sodium thio¬ 
sulphate may be employed and sodium carbonate may be injected to 
counteract the action of acids. After poisons have had opportunity for 
absorption attempts to hasten elimination are sometimes made. The re¬ 
sults have not been highly successful. At times, however, some of the 
measures to be employed are of value. It is, of course, evident that stimu- 


TREATMENT OF POISONING 


165 


lation of the renal function will undoubtedly aid in ridding the body of 
poison. In choosing a diuretic it should be remembered that water is 
the best diuretic known. It should be given in large volumes, from four 
to eight liters in twenty-four hours, if maximum beneficial results are 
to he realized. Hypodermic injection of 0.9 per cent solution of sodium 
chlorid repeatedly given in liter quantities will also increase urinary 
excretion. Intravenous infusion of the same solution may at times be 
employed. Venesection may he of value in some types of poisoning but 
the blood drawn (up to a liter) should be replaced immediately by an 
equal or double volume of isotonic salt solution. 

Another class of antidotes is the so-called group termed “physiological 
antidotes” or “physiological antagonists.” These antidotes do not really 
nullify the effects of poisons; they merely mask the symptoms produced. 
They are employed only against absorbed poisons and tend to combat 
the symptoms produced by arousing the opposite action. In this way they 
sometimes are of value in carrying the patient over a critical period and 
aid in conserving life. Some of the physiological antagonisms are atropin 
to pilocarpin, caffein to morphin, strychnin to nicotin, chloral to strychnin, 
atropin to morphin, chloroform to strychnin, etc. 

Symptomatic Treatment. —In most cases of poisoning, symptoms pro¬ 
duced by the absorbed poison are the most dangerous and these should 
receive attention from the beginning of the treatment. One of the first 
functions to fail is the respiration. Treatment to sustain respiration 
should not be delayed until respiration has actually ceased, but reflex 
stimulation of the respiratory center should be begun as soon as any evi¬ 
dence is given of the weakening of respiration. For this purpose use 
may be made of inhalation of ammonia water, or smelling salts, or ad¬ 
ministration of aromatic spirits of ammonia (half a teaspoonful in a 
glass of water), whipping with wet towels, mustard plasters, etc. Or if 
desired, agents to act directly upon the respiration may he employed, such 
as hot coffee, atropin (0.001 gram) or strychnin (0.002 gram). If none 
of these measures is effectual artificial respiration should be practiced in a 
manner to avoid injury to the lungs. 

In certain types of asphyxiating gas, such as CO, oxygen inhalation 
alone or inhalation of oxygen with small percentages of C0 2 may be of 
benefit. 

In attempting to stimulate the poisoned heart intravenous infusion of 
isotonic salt solution alone or with the addition of epinephrin (1: 100,000) 
may be of value. Dilatation of the heart may be relieved by venesection. 
The patient should be kept quietly in bed, cooling prevented by applica¬ 
tion of heat, pain controlled by anodynes, convulsions counteracted by 
chloroform, and coma combated by stimulants such as coffee or atropin. 

For poisoning cases the following suggestion by Sollmann is highly 
recommended: 


166 


PRINCIPLES OF TOXICOLOGY 


“Antidotes for First Aid. —Every physician . . . should keep the 
following antidotes together, in a special satchel (‘Antidote Bag’) so that 
they can be readily transported. The dose should be written on each 
container. Amyl nitrite pearls; apormorphin tablets, 2 mg.; atropin 
tablets, 1 mg.; caffein-sodiuin benzoate; chloroform; cocain hydrochlorid 
tablets, 0.03 gm.; tincture of iodin; copper sulphate, powdered; lime- 
water; magnesia, calcined; potassium permanganate, 1 per cent solution 
(to be diluted twenty times); sodium sulphate; spiritus ammonise aro- 
maticus; strychnin sulphate tablets, 2 mg.; whisky; also a hypodermic 
syringe in good order, and a stomach tube with funnel. The following 
should be demanded at the house of the patient: boiled water; coffee 
(strong, hot, and black); eggs; hot-water bags; milk; mustard; salad 
oil; salt; soap; starch, boiled; tea; vinegar.” 

In criminal cases of poisoning the physician should carefully note and 
record the symptoms observed and take possession of any suspected sub¬ 
stances, such as medicine, food, drink, and he should also preserve vomitus, 
urine and feces. In the event of an autopsy where a chemical analysis 
is anticipated it is desirable that the chemist be present. In this way 
much more satisfactory correlation may be obtained in tracing the origin 
of the organs than if they are delivered to the chemist by the physician. 
Moreover, the chemist will also be able to testify that the vessels contain¬ 
ing the organs and tissues are chemically clean. 

In many instances it is deemed sufficient to examine the stomach and 
intestines for the presence of poisons. This, however, is not adequate 
practice. In addition to the tissues mentioned, portions of all the prin¬ 
cipal organs, including the brain, cord and urine of bladder, should be 
secured, especially if the nature of the poison is unknown. In the event 
that a quantitative estimation of the poison is called for, the total weights 
of the organs selected should be determined. The various organs and 
tissues should be preserved in separate vessels without addition of anti¬ 
septics and the chemical examination should be begun as soon as pos¬ 
sible after the autopsy, although.in most instances poisons do not rapidly 
disappear from the body after death. On the other hand, poisons that 
are gaseous or readily volatilized may disappear very rapidly after death. 

The autopsy itself may not reveal the cause of death. Indeed, in most 
cases of death by poisoning, the autopsy fails to show the cause of death. 
In this event chemical examination is relied upon to furnish the proof. 
At times even this fails, for the poison may have been largely eliminated 
and exist in any particular organ in quantities too small to be detected 
by present-day methods or it may be a poison for which there is no 
specific chemical test. In most instances, however, the chemical examina¬ 
tion may be relied upon to give the desired information. 

The autopsy is of great value in suspected poison cases, although no 
evidences of poisonous action on the organs and tissues can be demon- 


REFERENCES 


167 


strated even on microscopic examination, for it affords an opportunity 
to determine whether death can be ascribed to natural causes. In the 
event that the organs and tissues reveal no pathological aspects, suspicion 
of poisoning is even more firmly established. 


REFERENCES 

Bastedo. Materia Medica, 2d ed., W. B. Saunders Company, 1920. 

Blyth. Poisons; Their Effects and Detection, 5th ed., Van Nostrand 
Company, 1920. 

Buchanan. Forensic Medicine and Toxicology, 8th ed., E. and S. Living¬ 
stone, Edinburgh, 1915. 

Cushny. Pharmacology and Therapeutics, or the Action of Drugs, 7th 
ed., Lea & Febiger, 1918. 

Robert. Lehrbuch des Intoxicationen, 2d ed., Stuttgart, 1902. 

Kunkel. Handbuch des Toxikologie, Jena, 1899. 

Peterson and Haines. Legal Medicine and Toxicology, ii, 2d ed., 
W. B. Saunders Company, 1923. 

Sollmann. Manual of Pharmacology, 2d ed., W. B. Saunders Company, 
1922. 

Witthaus. Manual of Toxicology, 2d ed., Wm. Wood & Company, 1911. 


CHAPTER IV 


THE PRINCIPLES OF MEDICAL CLIMATOLOGY 
Henry Sewall 

Scope of the Subject. —In its physical aspects, climate is determined 
by the facts of meteorology, or science of the atmosphere; and this in 
turn is inseparable from physiography, which pertains to the structure of 
the earth, and the distribution of its various features. According to 
Hann, “by climate we mean the sum total of the meteorological phenomena 
that characterize the average condition of the atmosphere at any one 
place on the earth’s surface. That which we call weather is only one 
phase in the succession of phenomena whose complete cycle, recurring 
with greater or less uniformity, every year, constitutes the climate of 
any locality. Climate is the sum total of the weather, as usually ex¬ 
perienced during a longer or shorter period of time at any given season.” 

But in ordinary usage the word climate inevitably suggests a rela¬ 
tion between the physical conditions of earth, air, and water to be found 
in any place, and the sensations and activities of man. 

The vital relations of the physical elements of climate are well illus¬ 
trated in the distribution of the various forms of animal and plant life. 
Man himself, through his ability to make fire and clothing and to com¬ 
mand food, has been able to adapt himself to the widest extremes of 
climatic conditions. 

When a plant or an animal flourishes in a given locality, its organs 
and functions are said to be adapted to the conditions there found. To 
a great extent such forms, or their descendants, may be brought, by grad¬ 
ual change, to live in a totally different environment. 

This adaptability of living beings to widely different external con¬ 
ditions, through which forces which were once destructive become again 
conservative of life, depends upon a physiological reaction of the living 
organism to the influences acting on it. The physiological reaction of 
protoplasm to internal and external agencies determines the nature, the 
distribution, and the evolution of all forms of life. 

As we view the races of men in their habitats, from the poles to the 
equator, it is obvious that the differences between them are more or less 
dependent upon adjustment to their various environments. This ad- 
168 


SCOPE OF CLIMATOLOGY 


169 


justment involves not only the externals of clothing, the struggle for food, 
and the general habits of life, but strikes into social and moral relations, 
and results in anatomical differences, at least of form and color. What 
may be called 'physiological climatology seeks to determine what are the 
vital reactions especially evoked in various climates; what functions of 
the body are specifically stimulated or soothed; and what may be the 
effect, on the organism as a whole, of any definite climate. Human history 
is still too brief to enable us to certify whether limitations of physiolog¬ 
ical adaptation rigidly restrict the geographical distribution of a given 
race of men without fundamental change in their ethnographic characters. 
Caucasian peoples are rapidly claiming the whole earth, and it is a mat¬ 
ter of urgent moment to learn the natural adaptations they must acquire 
to conserve best their preeminence under new conditions. 

Until recently the problem of physiologic adaptation to climate has 
been inextricably confused with the incidental effects on man of the 
climatic distribution of pathogenic microorganisms. While the white 
man has acquired a certain degree of immunity against the infections 
common to temperate zones, he is so susceptible to the disease-provoking 
organisms teeming in the tropics that no fair opportunity has been al¬ 
lowed for his normal development in such regions. The migrations of 
the white race have been limited by the geographical distribution of 
pathogenic protozoa, and of certain insects which serve as their inter¬ 
mediate hosts. 

The extraordinary demonstration in Cuba, the Philippines, and the 
Canal Zone, that the infections which had threatened the lives of strangers 
in those regions are rigidly under control of Sanitary Art, for the first 
time gives the immigrant opportunity to adjust himself to tropical con¬ 
ditions. Enough has already been learned through the health reports 
from such localities to make it probable that morbidity and mortality 
among healthy adults, at least, are not essentially increased or accelerated 
by residence in tropical climates. As Clemow says: “Many-—almost 
the majority—of the ordinary infective fevers are most prevalent in 
the cool, and not the warm, season of the year.” In temperate climates 
the transmission of the most important infections depends more or less 
upon the intimacy of contact between the sick and the well; and the 
application of hygiene involves a regulation of sociologic relations. 

While these views of climatology have a broad bearing on ethnogeny 
and eugenics, interest is especially concerned with the influence of climate 
upon the sick man; or as an environment antagonizing the inception of 
disease. As the welfare of the human being in his conflict with disease 
depends, in general, on physiological reactions which lead to development 
of compensations, adaptations, or antidotes within the organism, it is 
obvious that the study of medical, no less than physiological, climatology 
has to do with vital reactions to climatic conditions. 


170 THE PRINCIPLES OF MEDICAL CLIMATOLOGY 


The first step should afford a comprehensive view of the physical 
elements of climate and the results of their combinations in actual climates. 
Then should follow an account of observations and experiments upon the 
physiological reactions of normal beings to the physical conditions of 
climate, singly and combined. Finally, consideration should be given to 
the natural distribution of diseases and to the effect of climates and 
climatic factors in conserving or antagonizing the forces of the human 
organism in its struggle with disease. Medical climatology must auto¬ 
matically shrink with the development of specific therapeutics and pre¬ 
ventive medicine. 

It is important to realize that, while man moves and breathes in a 
gaseous atmosphere, the protoplasmic units of which he is constructed 
are bathed in lymph which forms his true internal environment, the con¬ 
stancy of whose composition is far more important to normal life than is 
that of the circumambient air. 

When the normal alkalinity of the blood suffers a reduction there is 
immediate physiological reaction and the disturbance may be so profound 
as to destroy life. This condition of “acidosis” is the result of obscure 
and probably diverse causes. It is desired here to express the suspicion 
that the physiological relations of climate are largely achieved through 
a modification of metabolism, one of the results of which is an altera¬ 
tion of the acid-alkali balance of the blood. Similar results may follow 
stimuli as widely different as diet and psychic emotion. It is quite 
possible that physiological effects which we attribute to climatic change 
are often directly mediated through such plasma changes as have been 
indicated. 


METEOROLOGICAL CLIMATOLOGY 

Climates owe their characters to the quantitative relations of certain 
physical elements, the principal of which are: (1) temperature; (2) atmos¬ 
pheric moisture or humidity; (3) atmospheric movements or winds; 
(4) soil; (5) water; (6) light; (7) electricity. As will shortly be seen, 
various other relations are of salient importance. These are: latitude; 
the geographical distribution of land and water; ocean currents; the 
existence of mountain chains and elevation above the sea; insolation, and 
atmospheric composition, including impurities. Various factors of climate 
may have a different relative importance, according as they are viewed 
as agents affecting the physical conditions of the earth, or the welfare of 
forms of life upon it. The biologic importance of direct insolation and 
of winds far outweighs the physical influence of these factors. 

Temperature. —Probably the most important single factor of climate 
is temperature. With the sun vertical over the equator, a beam of energy 


METEOROLOGICAL CLIMATOLOGY 


171 


which covers a unit area of the earth would be distributed over a pro¬ 
gressively larger surface if deflected obliquely toward the poles. It is said 
that the amount of solar energy falling upon a given area along any 
meridian at midday varies approximately as the cosine of the latitude. 
Less heat, therefore, descends upon a given area of the earth with increas¬ 
ing obliquity of the rays. Moreover, as the shell of atmosphere enveloping 
the earth has, through its watery content, power of absorbing heat, it is 
obvious that oblique rays, which pursue a longer atmospheric path, are 
robbed of their heating power. Three conditions determine the insolation, 
or amount of solar energy, received at any place: 

1. The obliquity of the rays, according to which less heat falls upon 
a given surface; obliquity increases with latitude. 

2. The relative length of day and night. The ratio of day to night 
increases with latitude, in summer. As pointed out by W. L. Moore, 
“the rapidly increasing length of the day toward the poles during summer 
soon more than compensates for the decreasing angle at which the solar 
rays strike the earth”; so that during summer the insolation is actually 
more abundant at the poles than at the equator. 

3. The absorption of solar energy by the air. In dust-free air the 
absorption of heat depends upon the presence of contained watery vapor, 
carbon dioxid and ozone. There is reason to believe that in the upper 
atmosphere, above eleven kilometers, the amount of ozone is appreciable 
and constant. With increasing obliquity of the rays more air is traversed 
and more heat absorbed. Watery vapor and carbon dioxid have a specific 
absorptive power for the longer rays of the spectrum. 

Intensity of Insolation at Different Solar Altitudes (Moore) 


Altitude of the Sun 
in Degrees 

Relative Length of the 
Path of Rays 
through the Atmosphere 

Intensity of Insolation 
on a Surface 
Perpendicular 
to the Rays 

Intensity of Insolation 
on a Horizontal 
Surface 

0 

44.70 

0.00 

0.00 

5 

10.80 

0.15 

0.01 

10 

5.70 

0.31 

0.05 

20 

2.92 

0.51 

0.17 

30 

2.00 

0.62 

0.31 

40 

1.56 

0.68 

0.44 

50 

1.31 

0.72 

0.55 

60 

1.15 

0.75 

0.65 

70 

1.06 

0.76 

0.72 

80 

1.02 

0.77 

0.76 

90 

1.00 

0.78 

0.78 


Although the earth is actually nearer to the sun in the winter of the 
northern hemisphere than in the summer, the greater relative obliquity of 
the rays during the former season is the chief cause of its cold. In the 









172 THE PRINCIPLES OF MEDICAL CLIMATOLOGY 


southern hemisphere, on the contrary, summer occurs in perihelion and 
winter in aphelion. We should, therefore, expect to find a much greater 
difference between the extremes of annual temperature south than north 
of the equator. Meteorological observation shows that such is not the 
case; the northern hemisphere has a climate of extremes, while the south¬ 
ern hemisphere has a relatively equable climate. The explanation lies in 
the fact that the land of the globe is chiefly aggregated in the former and 
the water in the latter. This brings us to the consideration of the climatic 
relations of land and water. 

The specific heat of water is about four times that of land; that is, 
the same amount of solar energy would raise the temperature of a given 
body of land four times as high as that of an equal weight of water. 
Land is generally a poor reflector, but readily absorbs the heat falling 
upon it, and as readily gives it back to the air by radiation. Land is 
also a poor conductor, so that the heat absorbed is retained near the sur¬ 
face. Water reflects a considerable proportion of the incident heat. Water 
is a fairly good conductor, and the heat absorbed penetrates somewhat 
deeply and is evenly distributed. Heat reflected from the surface, or in 
evaporating the fluid, takes no part in warming the water. 

The difference in density induced by the equatorial heat and the arctic 
cold, respectively, leads to the establishment of a convection circulation 
in the water, of which the great ocean currents are the most striking 
manifestations. The warmed water of equatorial zones moves along the 
surface toward the poles, whence deep reverse currents sweep to the equa¬ 
tor to he warmed in turn. The Gulf Stream of the North Atlantic is 
generally credited with maintaining the temperature of the British Isles 
and northwest Europe far above that normal to the latitude. This effect 
is largely due to prevailing warm winds which blow from the sea. The 
influence of such air movement is to a great extent determined by the 
height of the coast line or the existence of mountain ranges parallel to 
it. Most littorals, and consequently to a greater or less degree the in¬ 
land surfaces, have their temperature modified from that normal to their 
latitude by the contiguity of either warm or cold ocean currents. The 
important consideration in this place is the general fact that large bodies 
of water oppose extremes and tend to conserve a uniform temperature. 

By the temperature of a place is meant the temperature of the air 
above it. This depends primarily upon the sun’s rays, but may be much 
modified by reflection or radiation of heat from neighboring surfaces. A 
sleeping room at night may he uncomfortably warm from the radiation of 
heat absorbed during the day, although the air without is cool. The 
streets of a city under the summer’s sun have, by reason of reflection and 
radiation of heat, a much higher temperature than is normal to the air. 
An overcast sky reflects the heat radiated from the earth and at night 
prevents the normal cooling of the air. Farmers protect delicate plants 


ATMOSPHERIC HUMIDITY 


173 


from frost by suspending over them a sheet which reflects the heat radi¬ 
ated from the ground. In fact, the conditions of temperature and mois¬ 
ture near the surface are apt to differ widely from those found at even 
slight elevations in the free air. The variations near the surface are 
extreme and rapid, and depend upon the physical properties of the soil 
and its covering. If there is no wind, a thin stratum of cold air may 
stay in contact with the ground, hut warm air would rise by convection. 
Therefore, meteorological observatories are elevated above the accidental 
influences of the surface. 

The true air temperature can only be obtained from a thermometer 
placed in the shade and removed from proximity to reflecting and radiat¬ 
ing surfaces. The temperature due to direct insolation, such as affects a 
person standing in the open, is measured by a special thermometer having 
a blackened bulb inclosed in a vacuum, and which is suspended in the 
sun. The lowest temperature of the day is registered shortly before sun¬ 
rise, while the highest comes an hour O-’ two after noon. Similarly, the 
warmest period of the year is about a month later than the summer sol¬ 
stice, and the coldest period follows the winter solstice after about the 
same interval. The mean temperature of the twenty-four hours is ob¬ 
tained by adding the figures of several observations, as those made at 7 
A.M., 2 P.M., and 8 P.M., and dividing the result by the number of 
readings. It is obvious that two places may have the same mean tempera¬ 
ture, while in one the diurnal temperature range is very great, and in 
the other very small, a matter of great physiological importance. A true 
estimate of the temperature changes of a place can only be obtained 
through records which show daily, monthly, and yearly means, as well as 
means of maximal and minimal temperatures for the same periods. The 
temperature relations of different places throughout the globe may be 
graphically portrayed and understood at a glance by the construction of 
isotherms. These are lines joining various stations having the same tem¬ 
perature (in general the mean temperature) at the same time. 

The isotherms of high southern latitudes, where there is relatively 
little land, run nearly parallel to the equator throughout the year. But 
in the northern hemisphere, containing the great continents, the isotherms 
in summer reach higher and in winter lower over the land than over 
the water. That is, once more, under the same variations of insolation, 
continental temperature changes are sudden and extreme, while oceanic 
temperature changes are gradual and moderate. 

Atmospheric Humidity.—Humidity denotes the moisture contained 
in the air. When the water is in the form of gas it is said to be diather- 
manous. But collected in the form of droplets, even if visible as clouds, 
it has great capacity for absorbing heat. Hence, in murky or cloudy 
weather, the changes of air temperature are less extreme than when it is 
clear. Temperature and humidity are almost inseparable in their cli- 


174 THE PRINCIPLES OF MEDICAL CLIMATOLOGY 


matologic and physiologic relations. The atmosphere always contains 
more or less watery vapor. The amount of vapor which it can contain 
without condensation into liquid particles increases with the temperature. 
A definite weight of water when evaporated will saturate a definite cubic 
space at a definite temperature. The amount of vapor thus sustained 
is nearly indifferent to the gases already present. If the temperature of 
a saturated space be lowered, part of the vapor will be condensed. If 
the temperature rises, more vapor can be sustained. The following table 
represents the maximal quantity of water that can exist as vapor in a 
cubic foot of space at various temperatures: 

Aqueous Vapor in a Cubic Foot at Various Temperatures 


Temperature 

Number of Grains of 
Aqueous Vapor in a 
Cubic Foot 

Temperature 

Number of Grains of 
Aqueous Vapor in a 
Cubic Foot 

100 ° F . 

19.8 

30 ° F . 

1.9 

90 ° F . 

14.8 

20 ° F .. 

1.2 

80 ° F .. 

10.9 

10 c F . 

0.8 

70 ° F .. 

8.0 

0 ° F . 

0.5 

60 ° F . 

5.7 

- 10 ° F . 

0.3 

50 ° F . 

4.1 

- 20 ° F . 

0.2 

40 ° F . 

2.8 




The actual amount of vapor contained in a given volume determines 
the absolute humidity. This, as just seen, has a maximum which increases 
with the temperature. The ratio of the amount of vapor actually present 
to that necessary to saturate the space at a given temperature is known 
as the relative humidity. 

Thus, if it requires ten grains of vapor to saturate a cubic foot of 
air at a given temperature, and but seven grains are actually present, the 
relative humidity is 70 per cent. The amount of vapor remaining the 
same, the relative humidity falls as the temperature rises, and vice versa. 
These relations gain their importance from the fact that the rate and 
amount of evaporation from a surface depend largely upon the capacity 
of the air for absorbing moisture. 

The lower the relative humidity the more powerful is the evaporating 
force. A knowledge of the absolute humidity of the air is sufficient for 
the purposes of the physicist, but the relative humidity expresses condi¬ 
tions of more physiological importance. Air at high temperatures can 
be “very dry,” and still contain more moisture than cool air, which is 
“very damp.” 

The atmospheric humidity is determined by the psychrometer, which 
consists of a pair of thermometers, the bulb of one of which is covered 
with muslin moistened with water. The mercury of the “wet bulb” in¬ 
strument stands at a lower level than that of the “dry bulb” to an extent 






















ATMOSPHERIC HUMIDITY 


175 


determined by the rate of evaporation from the moist muslin. The read¬ 
ings of the wet bulb are thought to represent the “sensible” or physio¬ 
logical temperatures more nearly than those of the dry bulb. The action 
of wind greatly accelerates evaporation; a low degree of humidity which 
might be comfortable in the still air of a room would be disagreeable in 
the moving air of the open. Some observers prefer to consider, not the 
relative humidity, but its complement, the “saturation deficit,” which is 
the percentage of vapor which the air lacks for its saturation. The dry¬ 
ing power of the air is determined by the percentage of watery vapor 
which is needed to saturate it. Thus at 30° C. (86° F.), with relative 
humidity 80 per cent, the amount of water that can still be taken up 
is about the same as when the air temperature is 10° C. (50° F.), and 
its relative humidity only 36 per cent. 

In changing from the liquid to the gaseous form, water absorbs a 
great amount of heat, rendering it latent and insensible to the thermometer. 
This heat of vaporization is taken from the air and especially the sur¬ 
face, from which evaporation occurs. When the vapor is condensed by 
falling temperature, its latent heat is returned to the air, and the cooling 
by that extent is checked. The “dew point” is the temperature at which 
vapor is condensed upon surfaces chilled by radiation below the satura¬ 
tion temperature of the air. 

The absolute humidity of any region depends, in general, upon the 
extent of water surface, including the moisture of vegetation, exposed 
to evaporation. It varies but slowly from time to time. The relative 
humidity, on the other hand, rises and falls rapidly, inversely with the 
temperature. It is higher in the morning than in the afternoon. The 
capacity of the air to hold moisture rises with the temperature. The 
rate of evaporation decreases with the rise of relative humidity, but in¬ 
creases with the temperature of the moist surface and especially with 
wind movement which removes the humid layer of air in contact with it. 
Evaporation is increased in high altitudes, both because of the lowered 
barometric pressure, and by reason of the low per cent of moisture in 
the air. As the amount of water which the air can hold depends upon 
the temperature of the latter, and as the temperature rapidly diminishes 
with altitude, it follows that most of the vapor is confined to the lower 
layers of the atmosphere. About half the watery vapor lies below the 
level of 6,500 feet, and nine-tenths below 21,300 feet of altitude (Hann). 
The intricate and profound relations of heat and moisture to physiological 
functions will be dwelt upon in a subsequent section. They largely regu¬ 
late both the metabolism of the body and its sense of well-being. 

Rain is due to the condensation of the vapor of the atmosphere when 
it is chilled to the dew point. The tiny droplets thus formed coalesce 
to a greater or less extent before they fall. Solid particles suspended in 
the air under ordinary conditions serve as condensation centers for the 


176 THE PRINCIPLES OF MEDICAL CLIMATOLOGY 


rain drops. It is said that in saturated, dust-free air condensation may 
begin on suspended ions. 

Rain washes and purifies the air and becomes of great hygienic im¬ 
portance to the atmospheres of large cities. Rain is more abundant in 
warm than in cold countries; and in regions where large surfaces of water 
are exposed to evaporation, provided the conditions for sudden chilling 
in the upper air are present, as on windward shores and in hill districts. 
Moisture-laden air, on striking a range of mountains, is deflected upward, 
and, being cooled, is apt to precipitate its moisture as rain on the wind¬ 
ward side. 

Winds.—The chief cause of wind is an unequal heating of the air. 
Air expands or contracts by 1/491 of its volume for every degree Fahren¬ 
heit of rising or falling temperature. Warm air is specifically lighter 
than cold air, and when masses of air at different temperatures are con¬ 
tiguous, they move down or up with velocities determined by the differ¬ 
ence of densities. The foundation of wind on temperature is simple in 
explanation, hut fundamental in importance. 

A patch of sandy soil gets hotter under the sun than a surrounding 
surface of clay. The superior radiation from the sand heats the air 
just above it, and the heated air rises as if in a chimney, the cooler sur¬ 
rounding air continually pressing in and replacing it at the surface, to 
be warmed in turn. The column of expanded air, on reaching a greater 
or less height, flows over upon the surrounding bed of cooler atmosphere. 
Wind is the movement necessary to the restoration of equilibrium of 
density throughout the atmosphere. As aqueous vapor is specifically 
lighter than either oxygen or nitrogen, a given volume of moist air is 
lighter than that of dry air at the same pressure and temperature. Hu¬ 
midity is, therefore, a cause of winds. Winds are classified as perma¬ 
nent, periodic, and non-periodic. “To the permanent winds belong the 
trade winds, the antitrades, and the prevailing westerlies of high lati¬ 
tudes ; to the periodic winds belong monsoons, land and sea breezes, moun¬ 
tain and valley breezes; to the non-periodic winds belong the high winds 
that accompany cyclones and anticyclones, including the hurricane of the 
West Indies, the typhoon of the China Seas, the simoom of Arabia and 
Africa, the sirocco of Italy, the fohn winds of the Alps, the chinook 
winds of the northwestern part of the United States, the mistral of Eu¬ 
rope, the Texas northers, the blizzards, and the hot winds of our western 
plains, tornadoes, the thunderstorm gusts, whirlwinds, and many others.” 
In this article only the general features of the subjects can be discussed. 

Warmed air rises as it expands, and cooled air descends as it con¬ 
tracts. The contrast between currents of different temperatures is par¬ 
ticularly obvious where they. are confined, as among the slopes and val¬ 
leys of a mountainous region. Uniform terrestrial wind movements 
largely depend upon the heating of the air in equatorial regions. A 


WINDS 


177 


vertical motion is tlius given to the medium and the air, being heaped up 
in the higher altitudes, flows off north and south to about latitude 30°, 
where, having become denser than the supporting medium, it descends to a 
greater or less extent in a vertical direction. Air currents on the sur¬ 
face of the earth have, of course, the reverse direction to those above. 
The dense air of the polar circles flows equatorward until it meets the 
surface currents moving poleward, when it ascends vertically, to be dis¬ 
tributed again according to the relative densities. As Phillips puts it: 
“The final result would he surface winds on the equatorial sides of 
latitude 30° toward the equator, and on the polar sides toward the poles; 
surface winds within the polar circles toward the equator; regions of 
variable winds and calms at the equator, latitude 30°, and the polar 
circles. The circulation, however, would still be along meridians.” These 
ideal relations are somewhat changed by the axial rotation of the earth. 
As the actual velocity of rotation on a meridian increases from pole to 
equator, a mass of air moving southward is, in the northern hemisphere, 
left behind its appropriate meridian and becomes directed southwest. 
The result of this motion is seen in a deflection of meridianal currents, 
so that in the northern hemisphere north winds become northeast, and 
south winds become southwest in direction. In the southern hemisphere 
the deflections would be complementary. 

The so-called trade winds of lower middle latitudes have their ex¬ 
planation in such rotational deflections of meridianal currents. Such re¬ 
lations hold well over the oceans, but the modification of temperature con¬ 
ditions over continental areas, and especially the obstructive and cooling 
influence of mountain ranges, complicate the actual wind movements. 

The orderly connection between temperature and wind is familiar in 
the daily land and sea breezes on the coast line of any large body of water. 
The specific heat of land and water being about as 1 to 4, the land is 
rapidly heated in the day time, and the air expanding above it flows sea¬ 
ward in the upper regions. The cooler air over the water takes the re¬ 
verse direction along the surface, thus giving rise to the tempering sea 
breeze of a summer’s day. At night the land rapidly loses heat by radia¬ 
tion, and the air above it becomes more condensed than that above the 
water. The result is a nocturnal land breeze which lasts until temperature 
equilibrium is again reached. 

Cyclones and Anticyclones .—During summer the excessive heating 
of continental areas leads to the generation of upward air currents many 
hundreds of miles in diameter. The lowest barometric pressure under 
such an expanse of upward motion is about at its center. The denser 
surrounding atmosphere flows in from all directions along the surface 
toward the point of lowest pressure. The actual direction of wind move¬ 
ment, however, is not radial toward the “low” center, but, following the 
law of meridianal motions, the currents in the northern hemisphere take 


178 THE PRINCIPLES OF MEDICAL CLIMATOLOGY 


a circular direction opposite to that of the hands of a watch. Such a 
system of wind movement is known in meteorology as a cyclone . Con¬ 
versely, when a column of air becomes heavier than the atmosphere in 
general, as commonly happens over continents in winter, the denser air 
moves vertically downward and passes outward along the surface from 
this center of high barometric pressure. For obvious reasons, the direc¬ 
tion of wind motion in such a case is, in the northern hemisphere, like 
that of the hands of a watch. Such a system of wind movement is known 
as an anticyclone. The physiological effect of the cold, dry, pure air 
thus brought to the surface is one of invigoration. The reader is referred 
again to the comprehensive work of Moore for a graphic account of the 
meteorological bearings of this subject. Winds are of very great impor¬ 
tance in medical climatology. They may furnish in turn the most grate¬ 
ful relief from the depressing effects of heat and moisture, or render an 
otherwise enjoyable climate unbearably rigorous. 

Altitude.—The factors of climate are more or less modified with 
elevation above sea level. The weight of the atmosphere and, therefore, 
the barometric pressure decrease progressively in a vertical direction from 
the surface of the earth. When the barometer reading at sea level is 
29.97 inches Hg, at an elevation of 5,000 feet it is about 24.97 inches, 
and at 10,000 feet 20.39 inches. The rate of fall decreases progressively. 
In the first 1,000 feet of elevation the pressure is lowered by 1.15 inches 
Hg, in the tenth 1,000 feet by only 0.77 inch Hg. According to Boyle’s 
law, the volume of a gas varies inversely with the pressure, the tempera¬ 
ture remaining the same. Therefore, the atmosphere is progressively 
rarefied with increasing altitude; the proportion of its constituents 
remains the same. At an elevation of about 3.5 miles, or 18,480 feet, 
the pressure is reduced to about half that of sea level. Permanent human 
habitations occur at altitudes approximating this (oyer 16,000 feet in 
Thibet and Bolivia—Hann). As the weight compressing the air de¬ 
creases with elevation, air expands; and in expanding absorbs from the 
surroundings heat which becomes latent because doing the work of expan¬ 
sion. On returning to a lower level this latent heat is given off again 
when the air reaches its original volume. Dry air falls in temperature 
about 1° F. for every 183 feet of elevation. When the air is moist this 
relation is disturbed by the latent heat set free from condensing watery 
vapor. Over the equator continuous snows are found on mountains at an 
altitude of 18,000 feet. The snow level north and south descends with 
increasing latitude, and varies with the season. Mountain tops are said 
to be cooler than the free air about them, though the rate of temperature 
decline is less on mountain slopes than in the free air, and over elevated 
table lands the temperature decrease is much more gradual. The useful¬ 
ness of these facts depends upon their adaptation to surface conditions at 
various elevations. 


ALTITUDE AND SOIL 


170 


Watery vapor follows the law of expanding gases and decreases per 
volume of air with ascent; moreover, the amount held in solution is 
reduced by the lowered temperature (see table, page 174). 

Solid particles, which form an adventitious but constant constituent 
of the atmosphere at low levels, decrease with ascent above the surface. 
The air upon high mountain slopes has been found free from dust and 
bacteria. The result of these conditions has more physiological than 
physical value. Vegetation is sharply limited, owing to the falling tem¬ 
perature on the slopes of high mountains, as shown by the “timber line/’ 
which is higher on southern than on northern exposures. 

Pure, dry air is nearly diathermanous. Solid particles, carbonic 
acid, and especially water in suspension are the atmospheric elements 
chiefly capable of absorbing heat. We therefore find that their reduction 
in elevated regions is manifested by increased intensity of insolation. 
A surface capable of absorbing heat becomes excessively warm under the 
sun’s rays, but, the air being cold, a thermometer placed in the shade 
shows a low degree of temperature. The heat-absorbing constituents of 
the atmosphere also operate specifically upon the less refrangible rays of 
the spectrum. Therefore, solar heat and light are not only more intense 
in the clear air of high altitudes, but the proportion of “chemical” rays 
is greater than at sea level. 

The science of aerology has achieved such rapid development that in¬ 
vestigators are more and more confidently using its data in the explanation 
of puzzling records of geologic events, such as the glacial epochs. 

While meteorology may be considered a parent of climatology, their 
interdependence must be worked out empirically for every complex of 
conditions. 

The present status of our knowledge is well set forth in the recent 
monograph of Humphreys. He writes: “The atmosphere is divisible 
into the stratosphere and the trophosphere; or the isothermal region 
(with a temperature of about minus 55° C.) and the convective region; 
or, in other words, that region in middle latitudes at and beyond about 
eleven kilometers above sea level, where, because of freedom from vertical 
convection, ordinary clouds never form, and that other, or turbulent, 
stormy region below this level, which is frequently swept by clouds and 
washed by snow and rain.” 

Soil.—The nature of the soil found in any locality is an important 
climatic factor. Soils differ greatly in their capacity for absorbing and 
radiating heat, and for holding water. Estimating the capacity for heat 
absorption and radiation of sandy limestone at 100, that of pure sand is 
96, that of various clays varies from 67 to 77, while that of humus is 
only 49. It has been found that a layer of sand half an inch or more 
thick on marshy ground so increases its absorptive power that the radia¬ 
tion at night suffices to prevent the freezing of crops that would otherwise 


180 THE PRINCIPLES OF MEDICAL CLIMATOLOGY 

suffer. The greatest range of temperature is found where the land has 
the greatest power of absorption and radiation, as over deserts. The char¬ 
acter of the soil has especial importance in its relation to the absorption 
and retention of water. Sand absorbs water most readily, but allows it 
to percolate rapidly. Therefore, a sandy surface quickly dries after a 
heavy rain, unless underlaid by an impervious layer. Clay absorbs water 
with difficulty, and gives it up slowly. Humus has extraordinary capacity 
for absorbing water, which it takes up slowly, but retains strongly. Damp 
soils are those which retain or prevent the percolation of water. Cultiva¬ 
tion of the ground greatly enhances its capacity to store water. The 
atmospheric humidity varies with the moisture in the soil, and the tem¬ 
perature relations of the air approach in equal degree those found over 
water surfaces. The reflecting powers of the ground covering are of 
physiological moment, as witnessed in the glare from sandy deserts on 
the one hand, or mountain snow fields on the other. 

Electricity. —Electricity is a climatic factor of unknown value. It is 
said that the atmosphere is usually positively electrified with regard to the 
earth, and that the open air is positive to that within dwelling's. During 
rain storms the air charge is said to become negative. In the dry air of 
elevated regions the house dweller is often painfully reminded of his elec¬ 
tric potential by the shock that follows his touch of a grounded conductor. 

There may be truth in the popular conception that ozone has impor¬ 
tant climatological relations. It is a powerful oxidizing and purifying 
agent. It is formed from oxygen under the influence of electric dis¬ 
charges produced by many and various meteorologic and telluric condi¬ 
tions, or by the action of ultraviolet rays. In general, its presence in¬ 
dicates the absence of organic pollution, and is associated with a bracing 
physiological effect of the air. 

In the presence of moisture and at ordinary temperatures it quickly 
reverts to ordinary oxygen; but at very high altitudes, where the tempera¬ 
ture is about minus 55° C., it is supposed to be formed under ultraviolet 
radiation from the sun and its condition is far more stable. 

Composition of the Atmosphere. —The composition of the free air 
in different places is remarkably uniform. This is given for pure dry 
air by Moore in the following: 


Composition of the Atmosphere 



By Volume 

By Weight 

Nitrogen . 

78.04 

75.46 

Oxygen . 

20.99 

23.19 

Argon . 

0.94 

1.30 

Carbon dioxid. 

0.03 

0.05 



100.00 

100.00 













COMPOSITION OF ATMOSPHERE 


181 


Other gases, such as krypton, neon, etc., which occur in small amounts, 
are without known effect. A small trace of ammonia, important to plant 
life, is said to be normally present. A most important and variable con¬ 
stituent is watery vapor, which ranges in amount from 3 per cent of 
volume in the dampest regions, to a vanishing proportion in the dryest. 
The percentage of the different components of the atmosphere, with the 
exception of the watery vapor, is practically unchanged by altitude. 

Barometric Pressure. —This is the sum of the partial pressures of 
all the gases in the atmosphere. While the total pressure is due to and 
measures the total weight of the air-cone supporting the mercurial col¬ 
umn, the partial pressures of the various components of the air do not 
exactly measure their relative weights. “Equality between partial pres¬ 
sures and weights would hold if the percentages of the gases present re¬ 
mained constant throughout the atmospheres; but when the percentage of 
any substance decreases with elevation, the pressure it exerts is correspond¬ 
ingly greater than its own weight. Thus the pressure of water vapor 
at the surface of the earth is about six times its weight, or sixfold what 
it would be if the gases were not present/ 7 

The atmospheric pressure at sea level in fair weather is usually rep¬ 
resented by a mercurial column 760 millimeters, about 30 inches, high. 
The pressure decreases regularly with altitude, but its decline is affected 
by latitude, temperature, and humidity. The barometric fall for equal 
ascents becomes slightly less with increasing altitude. Roughly estimated, 
the barometer falls 1 mm. for every 12 meters ascent, or 1 inch for each 
328 yards above sea level. 

Dust and Impurities in the Atmosphere. —The hygienic relations of 
atmospheric purity will be referred to later. Except in the uninhabited 
regions of high altitudes, and to a degree over the oceans, dust particles, 
including microorganisms, are constantly suspended in the air. “The 
air of large cities invariably shows hundreds of thousands of dust-motes 
to the cubic centimeter, that of the village or town thousands, and that 
of the open country at least hundreds. 77 Light striking upon the sus¬ 
pended dust particles is scattered in all directions. They are the chief 
elements in the diffusion of daylight. In dust-free air only objects would 
be visible which were illuminated by the direct rays from the sun or 
those reflected from visible surfaces. Tyndall found in his experiments 
that the dust most difficult to remove was combustible, and therefore com¬ 
posed of organic matter. 

The color of the sky, the duration and colors of twilight, are largely 
determined by the optical effects of dust-motes in the upper air. But 
dust owes its particular climatological importance to the fact that its 
particles serve as the condensation centers which seem to be necessary to 
initiate the formation of droplets of moisture which give rise to fog, 
cloud, rain, and snow. 


182 THE PRINCIPLES OF MEDICAL CLIMATOLOGY 


The Influence of Vegetation on Climate. —Forests have an important 
human interest in their efficiency as wind brakes. Radiation and evap¬ 
oration are increased over verdure-covered areas and, therefore, the gen¬ 
eral influence of vegetation is to cool the soil. The average humidity of 
the air of forests is several degrees above that of the open. The general 
effect of such growths is to conserve uniformity of temperature and 
moisture and to oppose extremes. Only a few years ago it was generally 
assumed that vegetation, and especially forestation, had extreme impor¬ 
tance both in increasing rainfall and in improving the capacity of the 
soil to absorb and retain water. Deforestation has been charged with 
causing aridity of once fertile regions on the one hand, and with allow¬ 
ing the rapid run off of excessive precipitation in disastrous floods on 
the other. An unprejudiced analysis of climatologic facts has led to the 
conviction that vegetation is only an effect and not a cause of rainfall. 
Numerous factors are involved in the problem. 

Professor Willis L. Moore finds that: “In New England, where de¬ 
forestation began early in history, the mean of the fluctuations in the 
rain curve is a steady rise since 1836 up to a few years ago; and in the 
Ohio Valley, where the forest area has been greatly diminished, there is 
no decrease of rainfall shown by the average of the fluctuations of the 
curve.” He concludes: “Precipitation controls forestation, but foresta¬ 
tion has little or no effect upon precipitation. . . . The run-off of our 
rivers is not materially affected by any other factor than the precipitation. 
Floods are not of greater frequency and longer duration than formerly.” 
It appears that the capacity of soil to absorb and retain water is enhanced 
rather more by artificial cultivation than by mere vegetation. The binding 
power of vegetation upon the soil is an important consideration. 

On the other hand, the existence and distribution of plant life are 
directly dependent upon temperature and humidity. Good crops are 
raised by “dry farming” in regions, such as Colorado, where the rainfall 
is insufficient to support spontaneous growth. The main feature of the 
method consists in fine trituration of the surface soil. It seems obvious 
that lumping of the earth in masses would not only facilitate the develop¬ 
ment of macroscopic interstices, favoring a run-off of water, but would 
impede the penetration of the clods. On the other hand, pulverization 
of the soil would both annihilate its drainage channels and set each par¬ 
ticle free to exert its maximum adsorption on the falling moisture. The 
distribution of plant life in general, other things being favorable, is deter¬ 
mined by temperature ranges. Plant growth does not take place until a 
temperature of about 43° F. is reached. The amount of growth depends 
upon the number of hours in a season in which the temperature is above 
this limit. Of two places having the same mean temperature, one may be 
barren and the other contain a rich flora through favor of a short, hot 
summer. 


PHYSIOLOGICAL AND MEDICAL CLIMATOLOGY 183 


PHYSIOLOGICAL AND MEDICAL CLIMATOLOGY 

The living organism responds to its physical environment. While 
each climatic factor has a preponderant effect upon one or another physio¬ 
logical function, the fact that these functions are interdependent and that 
climatic conditions vary more or less as a whole makes the study of physio¬ 
logical climatology one of exceeding complexity. The ideal scientific 
presentation of the subject would denote the relations between climate and 
the living organisms in the form of an equation. On one side would 
be grouped the physical variables entering into the concept climate; on 
the other side would stand the infinitely complex community of reacting 
cells of the body. The science of medical climatology must attempt to 
present the integral effects upon the second term of the equation of muta¬ 
tions in the variables of the first. This underlying mathematical concep¬ 
tion of the subject is manifest in the actual examination by the labora¬ 
tory worker of the physiologic effect of the change of individual climatic 
factors. Moreover, the mathematical point of view has definite practical 
value in that it reveals the futility of expecting a solution of the problem 
without a full knowledge of all the variables which enter into it. 

The Physiological Reaction to External Temperature.—Temperature 
is biologically the most dominant factor of climate. Metabolism of living 
matter goes on within a narrow range of body temperature. Cold-blooded 
animals, whose chemical processes in large measure rise and fall with 
external temperature, have, like plants, a geographical distribution strictly 
related to the thermal environment. Warm-blooded animals react to 
variations of external temperature in such a way that, in general, metab¬ 
olism with production of heat is increased and loss of heat decreased by 
external cold, while the reverse reactions occur when the external tem¬ 
perature rises. By these means a nearly constant body temperature is 
maintained under wide fluctuations of air temperature. 

The heat of the body is due to katabolism, or the breaking down of 
complex into simpler chemical compounds, in which process potential 
energy becomes liberated and kinetic. The food is the fuel which sup¬ 
plies the body with all its energy, and there is believed to be an exact 
equality between the energy, estimated as heat, lost to the food in the 
body and that set free in the vital processes, supposing the weight of the 
body to remain the same. Therefore, the body in its metabolism is sub¬ 
ject to the law of the conservation of energy. 

Observations on men confined in a calorimeter show exactly how much 
energy, estimated as heat, is lost to the body under different conditions 
in a given time. It is obvious that, to maintain the body unchanged, it 
must receive in the food at least as much energy as it loses in its metab¬ 
olism (for the full value of food, etc., see Chapter II of this volume). 


184 THE PRINCIPLES OF MEDICAL CLIMATOLOGY 


Parallel with the increased ingestion of heat-producing food, physio¬ 
logical combustions are increased in the cold, otherwise the level of body 
temperature could scarcely he maintained. The four-fifths or more of 
the energy of muscular contraction which appears as heat, not to speak 
of the warmth from circulation friction, are important sources of bodily 
heat. All these facts harmonize with the ethnic experience that, broadly 
speaking, the peoples of the higher temperate latitudes are characterized 
by physical energy and mental initiative, while those of torrid zones 
exhibit a comparative bodily lassitude and mental inertia. 

In actual climates other factors than temperature, notably humidity 
of the air, enter into the physiological problem and demand a special 
discussion. 

External temperature has a fundamental causal influence on body 
metabolism. It is a fair assumption that there is an optimum metabolism 
at which machine efficiency of the organism is at its acme, and that this 
condition represents the most perfect attainable standard of good health 
for the individual. It seems probable, though it does not follow of neces¬ 
sity, that the ability of the tissues to adjust themselves to varying en¬ 
vironment, and to produce the various biological antagonists against 
infectious disease, should manifest an intimate dependence upon this 
physiological efficiency. In short, what we term a the resistance powers” 
of the body probably vary in some direct proportion with that harmony 
of metabolism whose optimum is manifested by perfect mechanical effi¬ 
ciency. Such a view finds luminous exposition in the clinical experience 
that an environment of open air provides the body with a more or less 
specific resistance against the advance of certain infections—notably tu¬ 
berculosis. It is commonly admitted also that tuberculous patients thrive 
better when they react to the cold of winter than when subjected to the 
heat of summer. It is fundamentally important to realize that the com¬ 
munity of living cells forming the body is a moving system, reacting 
instantly to every change of environment. The resultant of such a 
physiological adjustment is subtended by a state of consciousness, a sense 
of comfort or discomfort, of well-being or ill-being. This psychological 
condition is what determines man’s estimate of climate, and I assume 
that it is the natural and, on the whole, most reliable test of the con¬ 
servative or destructive tendencies of underlying physiological activities. 
Our appreciation of a change is always measured by the state to which 
we have already become adjusted. Thus, as Huggard points out, Ross 
and his party of Arctic explorers found the temperature of —29° to 
—25° F. agreeable after they had been exposed to one of —47° F.; 
and Peary’s men complained of heat at 26° F. after they had become 
accustomed to —13° F. 

Zuntz and his party in the Alps found that, in the springtime, after 
a winter’s inactivity, the guides suffered fatigue and metabolic disturbance 


LOSS OF HEAT 


185 


in climbing a certain height, which disappeared after the physical train¬ 
ing of a summer. Training is the process of physiological adjustment 
necessary in passing from one habit or environment to another. Every 
organism has its individual range of physiological response to the process 
of training. Somewhere on this scale, whether it be constructed on the 
basis of external temperature or any other climatic factor, is a point at 
which, for the moment, is found the optimum of physiological response 
—or that response which best conserves the well-being of the organism 
as a whole. The numerical situation of this optimum varies with the 
individual, and for the same person at ditferent times. Beyond the ex¬ 
tremes of the scale, life can no longer exist. 

The essential thesis of this argument is that climate, in its broad 
sense, is an indispensable factor in physiological therapeutics. 

The body temperature in man has been found by most observers to 
vary only within one degree during residence in opposite extremes of 
latitude. The accuracy of most observations is impaired because the 
records have been obtained from the mouth or axilla. This uniformity 
of body temperature under different external conditions is maintained 
by coordination between the nervous mechanisms for the dissipation and 
production of heat. According to Vierordt, the relative loss of heat 
through various channels is represented in the following table: 


Kelative Loss of Heat through Various Channels 


Channels 

Per Cent 

Calories 

By urine and feces. 

1.8 

47,500 

By expired air: warming of air. 

3.5 

84,500 

Vaporization of water from lungs. 

7.2 

182,120 

By evaporation from skin. 

14.5 

364,120 

By radiation and conduction from skin. . 

73.0 

1,791,820 

Total daily loss 


2,470,060 


The relative values of these factors change greatly with external tem¬ 
perature and humidity. Thus, in warm weather, the loss of heat result¬ 
ing from the evaporation of perspiration rapidly augments. The nervous 
mechanisms involved comprise the respiratory center, the vasomotor 
center, the sweat centers, certain other secretory centers, and the various 
afferent and efferent centers which connect them with the skin. The reg¬ 
ulation of heat production involves chiefly the motor nerve centers with 
the motor nerves of skeletal muscles, and the character and quality of 
the food ingested. Calorimetric experiments on men and animals show 
that the respiratory exchange, measured by the amount of oxygen absorbed 
and carbon dioxid exhaled, increases with fall of external temperature. 
In the case of man, the increase of oxidation through cold is insignificant 













186 THE PRINCIPLES OF MEDICAL CLIMATOLOGY 


if, by voluntary control, muscular movement and shivering are avoided. 
Thus is manifest the purpose of the instinctive muscular activity induced 
by falling temperature. Rubner found the amount of C0 2 eliminated by 
a fasting guinea pig in air cooled to 0° C. to be more than double what 
it was when at a temperature of 34.9° C. (94.8° F.) ; and this with a 
difference of but 1.2° C. in body temperature. 

The general conclusion from numerous researches on this subject is 
that the intake of oxygen and output of carbon dioxid increase with 
lowering, and decrease with rising, temperature of the environment. It 
is an interesting conclusion of Loewy that “the only involuntary regulator 
of temperature in a man exposed to moderate cold is the skin.” But 
the range of this coordination has definite limitations. Thus, both in 
man and animals, when the temperature of the calorimeter exceeds 30° 
to 35° C. (86° to 95° F.), the combustions of the body increase beyond 
their magnitude at 20° C. (68° F.). The writer has found that tuber¬ 
culous guinea pigs seem to fail faster if kept at temperatures between 
80° and 90° F. 

It seems very doubtful if such increased metabolism would be found 
in acclimated individuals living in the tropics. Pfluger made the inter¬ 
esting observation that, in a curarized rabbit, in which the muscles cannot 
be innervated, the gas exchange rises and falls with the external tempera¬ 
ture as it does in cold-blooded animals. The same effect was obtained 
in paralysis following section of the spinal cord in the neck. It is a 
matter of medical interest to know that several observers agree that 
anesthetized mammals respond like cold-blooded animals to alterations in 
external temperature. ( The student of metabolism should consult the mas¬ 
terly chapter of Graham Lusk on The Regulation of Temperature). 

The investigation of the effects of climatic temperatures, especially 
in the tropics, on physiological functions offers considerable difficulties. 
The conditions in hot countries are prone to be complicated by parasitic 
infections. Thus, according to some observers, a decided degree of anemia 
characterizes the inhabitants of hot countries, the number of red cor¬ 
puscles in the blood falling to half that normal in temperate zones. On 
the other hand, denizens of polar regions are said to show plethora and 
polycythemia. 

These conditions might be explained by abundant alimentation on 
the one hand, and parasitic infection on the other. The influence of 
warm countries seems to lower arterial blood tension. The rate of heart 
beat at the same time does not seem to be materially changed. Evidence, 
of doubtful value, obtained at surgical operations and postmortem examina¬ 
tions, indicates that residence in the tropics induces a hyperemia of the ab¬ 
dominal organs; on the other hand, the lungs contain less blood than usual. 

The general physiological effect of residence in hot countries seems 
to be epitomized in the muscular and nervous lassitude reported by resi- 


INFLUENCE OF ATMOSPHERIC HUMIDITY 187 

dents. The tendency is to a reduction in physiological tone; a lack at 
once in inhibitory force, and in active energy. 

Physiological Influence of Atmospheric Humidity.—The watery vapor 
diffused through the air has extraordinary physiological importance, 
not through specific action of its own, hut hy modifying the effects of 
other climatic agencies, as heat, cold, wind, and light. The vapor of water 
in the air, like a body of water upon the earth, tends to the preservation 
of uniform temperature. Watery vapor absorbs and renders latent a 
great deal of heat. The warmer the air the greater its capacity for sus¬ 
taining vapor, and thus accommodating a reserve of latent energy which 
must again become active when the vapor is condensed. Through at¬ 
mospheric humidity the earth is thus screened from the extreme intensity 
of solar insolation by day, and the earth is protected from extreme chill¬ 
ing through radiation and evaporation at night. The air in contact with 
a cooling surface is suddenly warmed when dew is precipitated. As 
already mentioned, the drying power of the air is measured by the per¬ 
centage of watery vapor which it lacks toward saturation; that is, it 
varies somewhat inversely with the relative humidity. 

It has been seen that the regulation of body temperature in man in¬ 
volves the regulation of the loss of heat by the skin. In cold weather the 
skin is relatively dry and the radiation of heat is reduced by proper 
clothing, and the body warmth is conserved on the principle of the 
domestic “fireless cooker.” As the external temperature rises, the skin 
circulation increases, and the sweat glands give forth their watery secre¬ 
tion. The evaporation of the sw T eat removes the excess of heat from the 
body. When the air is still, the relative humidity of the layer next to 
the skin is quickly raised so high as to impede further evaporation, the 
air seems “muggy,” and the subjective sensation is one of profound dis¬ 
comfort. A gentle breeze brushes away the moist coating, and the re¬ 
freshing cooling process continues. A stronger wind, especially when 
concentrated on a limited portion of the surface, is apt to occasion such 
rapid chilling as to cause widespread circulatory disturbances, which 
introduce a diversity of pathological conditions. Herein is a field for 
investigation which includes numberless phenomena, from the stiff neck 
that follows a draft, to the long list of respiratory infections that have 
some relation to surface chill. The discomfort occasioned by localized 
cooling of the body gives rise, in many people, to an instinctive aversion 
to drafts of air, which is worthy of special inquiry. Howell quotes a 
case from Zuntz of a man who possessed no sweat glands: “In summer 
this individual was incapacitated for work, since even a small degree of 
muscular activity would cause an increase in his body temperature to 
40° C. (104° F.), or 41° C. (105.8° F.).” This wonderful capacity 
of the body to regulate its temperature by evaporation was shown in the 
familiar experience of Blagden and Fordyce, published in the eighteenth 


188 THE PRINCIPLES OF MEDICAL CLIMATOLOGY 


century. These observers tested their own temperatures in rooms heated 
to various degrees. They found that the effect depended on the humidity 
of the air. “Thus, after remaining fifteen minutes in a damp room heated 
to 54.4° C. (129.9° F.), the temperature of the mouth and urine was 
37.8° C. (100° F.), but in a similar exposure in a dry room heated 
to 115.5° C. (239.9° F.), to 126.7° C. (302° F.)., and in which beef¬ 
steaks were being cooked bv the heat of the air, did not raise the tem¬ 
perature of the body above the normal.” 

It is clear that the chief regulator of the body temperature, as external 
heat increases, is evaporation of perspiration, and that the rate of evap¬ 
oration is closely dependent upon the relative humidity of the air. The 
sensory nerves of the skin give fine warning of insufficiency in the 
physiological regulation through disagreeable sensations which we ascribe 
to “mugginess” or “stuffiness” of the air, and which are remedied, as will 
he seen later, by air renewal through “ventilation.” When the external 
temperature falls much below that of the body, atmospheric humidity 
still has predominant interest, but in another direction. When the air is 
cold and its humidity high, the skin loses heat to the moisture by con¬ 
duction, which accounts for the peculiarly chilling effect of damp, cold 
air. Wind hastens this loss of heat, so that it is clear how the wind may 
make a hot day more tolerable and a cold one less so. 

Ventilation.—Perhaps the greatest clinical discovery of all time is 
the empirical determination of the hygienic and therapeutic value of the 
open air. We are not yet certain of the physicophysiological reactions 
which constitute the virtue of fresh air. 

Until recently it seemed clear that the subjective appreciation of air 
purity was a question of lrng ventilation. It was taken for granted that 
the “bad air” of a closed and crowded room exerted its influence through 
a rise in C0 2 tension and fall in 0 2 tension within the alveoli of the 
lungs. Moreover, it was held that the expired air contained organic 
excretions which imparted to it poisonous qualities. In short, the deleteri¬ 
ous effects of respired air were attributed to its chemical qualities. But 
Haldane and Priestley showed conclusively that, under a constant atmos¬ 
pheric pressure, the tension of C0 2 in the alveolar air remains practically 
constant. The slightest increase in such tension automatically stimulates 
the respiratory center to more vigorous action; “a rise of 0.2 per cent 
of an atmosphere in the alveolar C0 2 pressure being, for instance, suffi¬ 
cient to double the amount of alveolar ventilation during rest.” When 
a person under observation was made to rebreathe the air exhaled, he 
felt no abnormal subjective impressions until the C0 2 percentage in 
the air inhaled began to exceed 3 per cent. These authors found also that 
diminution of oxygen in the inspired air produced no reflex effect on 
respiratory rhythm until its pressure fell to about 13 per cent of an 
atmosphere, which corresponds to an alveolar oxygen pressure of about 


VENTILATION 


189 


8 per cent of an atmosphere, instead of a normal percentage of 11 to 17 
(Loewy). It is therefore obvious that, as regards its content of 0 2 and 
C0 2 j the alveolar air is not only practically identical outdoors and in, 
but that under ordinary conditions its variations make no impression 
on consciousness. Many years ago Brown-Sequard and D’Arsonval an¬ 
nounced that the deleterious qualities of expired air depended upon 
poisonous organic matter contained in it. They condensed the moisture 
in the breath of animals and injected the fluid obtained into other ani¬ 
mals with fatal effects. Other observers, repeating these experiments, 
failed to obtain the same results. Finally, the whole question was sub¬ 
mitted to an elaborate critical, experimental review in 1895 by Billings, 
Mitchell, and Bergey. These authors concluded that the ill effects of 
respired air depended wholly on its temperature and humidity, and 
not upon its increased content of carbon dioxid or any organic inclusion. 
Experiments, conducted by the writer, were recently instituted to de¬ 
termine whether a condition of sensitization could be induced in animals 
by confining them in jars ventilated insufficiently for their needs. Con¬ 
clusions were deduced as follows: 

“Guinea pigs exposed to the rebreathed air, including cutaneous dust, 
given off from other guinea pigs, until its content in C0 2 is sufficient to 
cause excessive dyspnea, manifest, in the majority of cases, when re¬ 
exposed to the same conditions after the lapse of from twenty to eighty 
days, in comparison with normal control animals, an exacerbation in 
respiratory disturbance which suggests anaphylactic reaction. 

“Though carbon dioxid is the only agent in the exhaled air which is 
demonstrated as the efficient cause of dyspnea, its presence is not neces¬ 
sary to the induction of the sensitive state; there is even some evidence 
that its presence tends to avert sensitization.” 

The writer has found that guinea pigs sensitized by subcutaneous in¬ 
jection of horse serum are, in a large proportion of cases, temporarily 
de-sensitized by exposure in a horse stable. This fact is crucial evidence 
that protein matter—whether from the skin or lung is doubtful—given 
off by the horse may, when inhaled by a guinea pig, produce in it im¬ 
munologic reactions. 

From a noteworthy series of researches performed by Paul, Heymann, 
and Ercklantz under the direction of Fliigge, the conclusion seems justified 
that the subjective impressions that we have been accustomed to ascribe to 
disturbances of lung ventilation really depend upon modifications of skin 
ventilation. The observations were made upon men confined in a closed 
chamber of three meters’ capacity provided with an electric fan. When 
the air was kept in motion by the fan, the subject under experiment 
remained free from unpleasant sensations in air which, measured by 
ordinary standards, was excessively foul. When the fan was at rest and 
the air still, the person confined in the chamber soon began to suffer 


190 THE PRINCIPLES OE MEDICAL CLIMATOLOGY 


from the headache, dizziness, fatigue, nausea, etc., characteristic of ex¬ 
tremely poor ventilation. In this condition the patient was allowed to 
breathe, through a tube fastened in the wall of the chamber, pure air 
from outside. Ho relief was experienced through this procedure; never¬ 
theless, when the fan was started and the air put in active motion, the 
person under experiment again became comfortable. 

Experiments by Leonard Hill and his colleagues have confirmed 
Fliigge’s contention, that the subjective impressions aroused by lack of 
ventilation in closed spaces are nowise dependent upon the chemical con¬ 
stitution of the air breathed, but rather on its temperature and its humid¬ 
ity, which interfere with the heat regulation of the body by restricting 
transpiration from the skin. The profound psychophysiological influence 
of temperature sensations derived from the skin is further evidenced by 
the curious fact observed by Boycott and Haldane, that when the air, 
whatever its real temperature, gave the impression of warmth of an 
unpleasant kind, the tension of C0 2 in the lung alveoli became lowered. 
They write: “We think, indeed, that it is one of the physical expressions 
of the feeling of warmth and slackness, while the rise in the C0 2 tension 
(in the alveoli) is associated with the general exhilaration and stimula¬ 
tion produced by cold air.” 

Rosenau and Amoss write: “Benedict has kept persons in his 

calorimeter breathing and rebreathing the same air with a C0 2 content as 
high as 2 per cent for twenty-four hours without discomfort, the only 
precaution being to keep the temperature down and to remove the 

moisture.” 

Hough describes an experiment in which a subject was confined for 
an hour or more in an air-tight box: “The percentage of C0 2 rose to 

50 or more parts per 10,000. When the observer opened the door the 

odor of the air within was almost overpowering; and yet, provided the 
water vapor was absorbed and the temperature of the box kept down, the 
subject of the experiment had not only been unconscious of this odor, but 
had actually suffered no discomfort.” In his excellent essay the author 
clearly indicates the physiological relations of atmospheric humidity with 
rising temperature. When the air temperature rises above 70° F., the 
body temperature would become elevated, but for the evaporation of 
perspiration. “When, however, owing to high humidity, evaporation is 
lessened, blood rushed in large quantities to the skin at the expense of the 
flow to other organs ; the temperature of the skin is raised, and so heat 
transfer by radiation, conduction, and convection is facilitated. The nor¬ 
mal temperature of the body is approximately maintained; but it is at 
the expense of the working efficiency of other organs, and especially that 
of the brain. ... In these facts we probably find the true explanation 
of the dull, heavy feeling, the difficulty of attention, and the discomfort 
both of the muggy summer day and of the crowded, ill-ventilated room. 


DIMINISHED BAROMETRIC PRESSURE 191 

• • • Humidity influences the output of heat from the body in two very 
different ways: It increases the conductivity of the atmosphere for heat— 
a cooling influence; and it interferes with the evaporation of perspira- 
tion—a heating influence. What the net result will be depends upon 
which of these influences of humidity is predominant.” It is pointed 
out that at air temperatures between 68° and 70° E. neither high nor 
low humidities have marked physiological effects while the body is at 
rest. This, therefore, is the optimum range of temperature for main¬ 
taining the comfort of inhabited rooms. 

Lee and Scott have recently reported experiments in which it was 
found that in cats, confined for six hours in a ventilated box where tem¬ 
perature and humidity could he regulated at will, the excised muscles 
at the end of this period showed a loss of work power when the air of the 
box had been maintained at high temperature and humidity (91° F. and 
90 per cent) as compared with normal conditions. The sugar content of 
the blood diminished 6 per cent under the same circumstances. 

The present writer has pointed out, as had M. J. Rosenau previously, 
on the basis of experiments in anaphylaxis, that substantial evidence 
exists for the absorption by the respiratory tract of protein matter diffused 
in the air with the result of producing profound changes in cellular 
irritability. Therefore, any practical view of ventilation which ignores 
chemical pollution of the air is unscientific and dangerous. 

Hiiggard quotes from Humboldt a striking description of the physi¬ 
ological conditions produced by hot, damp climates: “We had not yet 
been two months in the hot zone, and already our organs were so sensitive 
to the slightest change of temperature that, through shivering with cold, 
we were unable to sleep; and to our astonishment we saw that our ther¬ 
mometer registered 21.8° C. (71.24° F.). ... A change of not more 
than seven or eight degrees sufficed to bring about the opposite sensations 
of shivering and oppressive heat.” 

The temperature, humidity, and motion of the air combine to deter¬ 
mine physiological reactions of the utmost significance to the welfare of 
the body. Though the discomfort aroused by a poorly ventilated apart¬ 
ment may not, as demonstrated, be due to chemical deterioration of the 
air, nevertheless these sensations of ill-being lose none of their value for 
hygienic prophylaxis. The clinical experience which has demonstrated 
the debilitating effects of long-continued confinement in close air, as 
opposed to the invigoration attendant on life in the open, finds explanation 
in the respective influence exercised by the two environments over the 
general resistance powers of the body. The skin is a peripheral sensory 
organ specifically concerned in maintaining the hygiene of metabolism. 

The Physiological Influence of Diminished Barometric Pressure.— 
The mean pressure of the air at sea level may be assumed to balance a 
column of mercury 760 mm., about 30 inches, high. The total pressure is 



192 THE PRINCIPLES OF MEDICAL CLIMATOLOGY 


the sum of the partial pressures of all the components of the atmosphere. 
With elevation above sea level the fall in the barometer is measured by 
the mass of air left below. The rate of fall is approximately 1 mm. Hg 
for every 40 feet of ascent in free air, or 1 inch per 1,000 feet. With 
ascent the relative proportion of the constituent gases is maintained, ex¬ 
cept that the watery vapor is chiefly confined to the lower levels. Mere 
difference in atmospheric pressures appears, within wide limits, to be 
indifferent to living beings. The tension of the gases dissolved in the 
body fluids soon balances that of the surrounding air, so that the physio¬ 
logical phenomena of a rarefied atmosphere cannot be properly ascribed, 
as so often is done, to a suction-pump effect upon the pulmonary appara¬ 
tus ; although, it is true, a given amount of gas confined in the intestines 
expands in proportion to diminution of external pressure. 

The importance of the time element in the adjustment of internal to 
external gas pressure is well illustrated in the phenomena of Caisson- 
disease.” In subaquatic constructions workmen in caissons are sometimes 
subjected to air pressures of three or four atmospheres. On returning to 
normal conditions, if the decompression is too rapid, peculiar symptoms, 
tingling, cramps, etc., are experienced, and paralysis or even death may 
ensue. Postmortem examination shows that air emboli are set free in 
the central nervous system, leading to “necrosis in the region of the pos¬ 
terior and lateral columns of the cord, especially in the cervical region.” 
Such pathological results are avoided by slow decompression covering a 
period of one to two hours. The physiological effects of high altitudes are 
probably all to be explained by the lowered pressure of oxygen, and possibly 
of carbon dioxid also, in the alveoli of the lungs. In the dry atmosphere, 
at 760 mm. pressure, the partial pressure of oxygen is about 159 mm. 
That of carbon dioxid is negligible. 

Zuntz and Loewy 1 analyzed the air expired by human beings and 
calculated that the composition of alveolar air varied between the follow¬ 
ing limits: oxygen between 11 and 17 per cent of an atmosphere; car¬ 
bon dioxid between 3.7 and 5.5 per cent of an atmosphere. Or, in terms 
of tension, the partial pressure of oxygen ranged between 83.6 mm. Hg 
and 1-29.2 mm., while that of carbon dioxid varied from 28.1 mm. Hg 
to 41.8 mm. Attention has already been called to the demonstration by 
Haldane and his associates that, under ordinary conditions, the partial 
pressure of C0 2 in the pulmonary alveoli of a given person is remarkably 
constant. A very slight increase in the C0 2 tension leads to hyperpnea 
and exaggerated elimination of C0 2 from the body; while, on the con¬ 
trary, a lowering of C0 2 tension induces physiological apnea, or respira¬ 
tory rest, and consequent accumulation of C0 2 in the body. That is, 
C0 2 is the normal stimulus of the respiratory center. On the other 
hand, fluctuation of oxygen tension in the alveolar air may occur within 


1 Howell, W. H., Textbook of Physiology, 1907. 



DIMINISHED BAROMETRIC PRESSURE 


193 


wide limits without producing obvious reaction. Nevertheless, when the 
partial pressure of oxygen falls to a certain level, about 13 per cent of 
an atmosphere, the tension of the gas in the lung alveoli is so lowered 
that the body cells suffer from the lack of oxygen. 

Physiologists have generally maintained that the respiratory exchange 
between the alveolar air and the blood was regulated wholly by the physi¬ 
cal law for diffusion of gases. According to this law, a gas must pass 
from a medium where its tension is higher to one where it is lower, until 
there is equilibrium of tension. But Haldane and Smith maintain that 
the tension of oxygen in the blood leaving the lungs is much higher than 
that in the alveolar air, and, therefore, “diffusion alone does not explain 
the passage of oxygen from the air of the pulmonary alveoli to the blood.” 
Haldane, Douglas, Henderson and Schneider submitted the physiological 
influences of high altitudes to a searching investigation during a sojourn 
of thirty-five days on the top of Pike’s Peak, Colorado (elevation 14,000 
feet). They conclude that all the vital modifications witnessed at high 
altitudes are the result of one cause, lowering of the oxygen pressure 
in the air. 

They found, “after acclimatization the resting arterial oxygen pressure 
had risen about 35 mm. of mercury above the alveolar oxygen pressure, 
whereas, at or near sea level, the resting arterial oxygen pressure is no 
higher than the alveolar oxygen pressure. The raising of arterial oxygen 
pressure is attributable to secretory activity of the cells lining the lung 
alveoli, and is a most important factor in the acclimatization. On breath¬ 
ing air rich in oxygen, the secretory activity was rapidly diminished.” 
The fundamental significance of this alleged oxygen secretion, coordinate 
with the respiratory needs of the body, may well hold the attention. It 
has been shown bv Zuntz and others that the suboxidation of the tissues 
resulting from a critical lowering of alveolar oxygen tension is accom¬ 
panied by the accumulation of acid substances, especially of lactic acid, in 
the blood. These acid substances in the blood stimulate the respiratory 
center and lower its “threshold of irritability” for C0 2 , so that the cen¬ 
ter is excited to work under the stimulus of a lower tension of C0 2 in 
the blood than would normally be effective. 

It seems probable that this metabolic disturbance, which is particu¬ 
larly prone to affect newcomers in high altitudes, is directly responsible 
for many of the phenomena of mountain sickness. Mountain sickness is 
a curious symptom-complex manifested in various degrees by people who 
mount comparatively suddenly to high altitudes. In Europe the disorder 
is said to commonly manifest itself at elevations as low as 9,800 feet. 
In America the critical level seems to be considerably higher. The sub¬ 
jective symptoms are those of dyspnea, especially with exertion, and a 
feeling of oppression in the chest. 

Disgust for food and nausea leading to vomiting give name to the 


194 THE PRINCIPLES OF MEDICAL CLIMATOLOGY 


disorder. The sufferer is absorbed in his own misery, and the mental 
disturbance may proceed to temporary alienation. The skin and lips 
are blue, the circulation and respiration distressed, and the slightest 
exertion exaggerates intolerably all symptoms. The inhalation of oxygen 
gas relieves at once, for the time, the morbid condition. After a quiet 
sojourn of two or three days at the altitude provoking the sickness, the 
body usually becomes accommodated to the new conditions, and a fair 
amount of exertion may be taken without undue distress. Cyanosis of 
the skin disappears, the lips again become red, and pulse and respiration 
return to about normal. A review of the literature on mountain sickness 
would reveal a curious multiplicity of explanations for the disorder. The 
dogmatic statement may be ventured that the final cause of the symptom- 
complex lies in an inadequate oxygen supply. Haldane and his colleagues 
on Pike’s Peak found that, when samples of the venous blood were shaken 
up with air drawn from the alveoli of the lungs, the blood remained 
dark, although, at the same time, the arterial blood must have been bright 
red, as shown by the color of the lips and mucous membranes of the 
subjects. This experiment indicates both that the oxygen tension in the 
alveolar air was at least no greater than that in the blood from the right 
heart, and also that active absorption of oxygen by the alveolar epithelium 
must occur under such conditions. 

Clinical experiences have led the writer to suspect that an important 
factor, if not the internal exciting cause, in mountain sickness lies in 
circulatory disorder resulting in accumulation of blood in the venous 
system through inefficient cardiac action, proceeding to dilatation of the 
right heart, and, in extreme cases, to insufficiency of the tricuspid valves. 
It is easy to believe that anoxemia would early depress the cardiac func¬ 
tion. This would lead to plethora of the lungs and general venous system, 
and provoke the symptoms characterizing the disorder. Unfortunately no 
opportunity has yet occurred to try out this theory experimentally, as by 
a study of the jugular and liver pulsations. 

Physiological study of persons and animals removed from low to high 
altitudes shows a profound alteration in metabolism, especially of the 
hemopoietic system. The absolute and relative amounts of hemoglobin 
and of the red blood-corpuscles are greatly increased at high altitudes. 
Zuntz and his colleagues, working on Monte Rosa, altitude 14,960 feet, 
showed that the activity of the red bone marrow, as shown by its hyperemia 
and increased number of nucleated red cells, was accelerated by low 
barometric pressure. The number of red blood-corpuscles has been found 
to rise from 5,000,000 at .sea level to 8,000,000 at about 14,000 feet. 
The hemoglobin increases by 20 to 30 per cent or more under the same 
conditions. 

Haldane and his coworkers made a critical study of the blood as 
affected by barometric pressure. They found that “the percentage of 
hemoglobin increased for several weeks on the summit of Pike’s Peak 


DIMINISHED BAROMETRIC PRESSURE 


195 


and varied in various acclimatized persons from 115 to 154 per cent. 
The number of red corpuscles increased parallel with the hemoglobin.” 
At high altitudes symptoms of anemia may attend a hemoglobin per cent 
that is normal for sea level. 

Much of the work that has been done in this field is held by Burker 
and his associates to suffer from defects in method. These observers 
maintain that the increase in the red blood count for moderate elevations, 
up to, say, 10,000 feet, is much less than has usually been asserted. 

Abderhalden and others have considered the altitude-polycythemia to 
be the result, not of increased blood formation, but of blood concentration 
from excessive evaporation. Another view assumes that under low baro¬ 
metric pressures there is an unusual accumulation of corpuscles in the 
peripheral vessels from which estimations are made. The excellent work 
of Loevenhart and his colleagues seems to have disposed of these doubts 
as to the existence of a true altitude-polycythemia and the active stimu¬ 
lation of the blood-forming organs through reduction in the partial pres¬ 
sure of oxygen. 

Loevenhart confined rabbits in ventilated boxes in which, while the 
total barometric pressure was kept constant, the proportion of oxygen 
was widely varied. It was found that, under these conditions, low¬ 
ering the oxygen tension produced blood changes similar to those realized 
when a like fall in oxygen pressure was due to elevation above sea 
level. 

Reflecting on the reason for these changes in the blood, at first view 
there might seem a paradox of nature in the provision of an excess of 
oxygen-carrying material in proportion to the diminution of oxygen to 
be carried. On the other hand, the conception is incontrovertible that 
the hemoglobin of the body is not only a carrier, but a storehouse, for 
oxygen; and the excess, or luxus, of this stored oxygen must be greater, 
the lower the oxygen pressure in the alveolar air, in order to meet the 
demands of muscular activity. The relation of this respiratory “factor 
of safety” to the nutritional demands determining a physiological dietary, 
touched upon in a preceding section, is not without suggestiveness. Bar- 
croft and King have experimentally demonstrated the probability of 
hemoglobin serving, in certain lovrer animals, as a storehouse for oxygen, 
which is given up to the tissues as emergencies arise. The dissociation 
of oxygen from its carrier is greatly accelerated with rise of tempera¬ 
ture, and it is highly probable that the elevation of temperature occurring 
in active muscles is a definite device of nature to make loose the oxygen 
when needed. 

As regards the colorless corpuscles of the blood, G. B. Webb and 
his associates at Colorado Springs, altitude 6,100 feet, find that there is 
a relative and absolute increase in the number of lymphocytes, includ¬ 
ing especially the large mononuclears, in the blood of persons removing 
from lower to higher altitudes. They find that the proportion of lympho- 


196 THE PRINCIPLES OF MEDICAL CLIMATOLOGY 


cytes rises from an average of 37 per cent at sea level to 44 per cent at 
Colorado Springs, and to 54 per cent at Pike’s Peak. 

O. M. Gilbert of Boulder, Colorado, has repeated these observations 
at various altitudes varying from 9,000 feet above to 120 feet below 
sea level (in the Salton Sink of California). He found the highest ratio 
of lymphocytes (43.5 per cent) in the blood of persons residing below 
sea level. At Boulder, elevation 5,380 feet, the proportion of lympho¬ 
cytes was 42.6 per cent; at Phoenix, Arizona, 1,100 feet, 41.5 per cent; 
at Gold Hill and Ward, Colorado, 8,300 to 9,200 feet, 40.5 per cent; 
at Aurora, Illinois, 500 feet, 38.8 per cent. In short, the results indicate 
that the lymphocytosis is not a function of altitude per se, but of some 
other factor. 

Janet H. Clark refers to the lymphocytosis excited under certain ultra¬ 
violet rays, and possibly the excess of these rays, in the sunlight of special 
regions completely explains the metabolic change. 

Insolation.—In high altitudes the intensity of insolation is great be¬ 
cause the air holds but little moisture to absorb the rays; for the same 
reason, the heat radiated from the earth is not retained near the surface, 
but penetrates to upper levels. There is great difference, accordingly, 
between the temperatures of day and night, and between sun and shade. 
In winter an invalid may sit comfortably in a solar temperature of 90° 
to 100° F., while a thermometer hung in the shade within arm’s reach 
registers helow the freezing point. As it is the shorter wave-lengths of 
solar energy which are subject to atmospheric absorption, the light of 
elevated regions is peculiarly rich in these “chemical” rays. The intense 
illumination is probably largely responsible for the restlessness and irri¬ 
tability witnessed in unacclimated persons at high altitudes. 

The physiological and psychic influence of light makes it a climatic 
factor. Major C. E. Woodruff charges the intense solar illumination 
with the evils, especially of the nervous system, which make difficult the 
residence of white people in the tropics. 

According to him, light is the important agent in the production of 
neurasthenia and multifarious allied nervous disorders, and persons of 
blond complexion are especially subject to its evil influences. It seems 
highly probable that the debilitation induced in the tropics is due rather to 
the combined influences of heat and humidity, than to excessive illumina¬ 
tion. Light is indispensable to normal life, and, if its excess leads to phys¬ 
iologic disturbance, it becomes all the more imperative for the climatic 
therapeutist to consider this agent specifically in his recommendations. 

The radiant energy of the sun is undoubtedly a powerful physiological 
stimulus, capable of working either good or harm to the body. Helio¬ 
therapy is in an empirical stage. Such experiences as those of Rollier, 
in the cure of surgical tuberculosis under sunlight, deserve critical con¬ 
firmation. Webb correctly urges caution in the application of the method. 


INSOLATION 


197 


The writer saw one of his patients who had apparently cured himself 
of a severe ulcerative tubercular laryngitis by the daily application, for a 
few minutes, of sunlight to his larynx. The light was reiiected by a pair 
of polished metal mirrors and guided by a laryngoscope. Lt was presumed 
that the ultraviolet rays, probably excessive in the Colorado sunlight, were 
the efficient agent. 

The study of the vital reactions to light, and especially to ultraviolet 
rays, has become an important and rapidly developing branch of phys¬ 
iological physics. Edgar Mayer has brought together much information 
on this subject from the therapeutic viewpoint. 

Under certain conditions visible light assumes as drastic a physi¬ 
ological role as the ultraviolet rays. As noted by Mrs. Clark, “it is 
possible to sensitize living cells, just as one sensitizes a photographic 
plate, and produce an abnormal condition in which visible light is as 
active as ultraviolet. This phenomenon has been called photodynamic 
sensitization. . . . Although a great many substances sensitize in vitro, 
only eosin, chlorophyll and certain derivatives of hemoglobin have so 
far been found effective in vivo and the only markedly effective sensitizer 
for higher animals is hematoporphyrin. This substance is derived from 
hematin by removing the iron.” It is said that traces of hematoporphyrin 
occur normally in the urine, but the quantity becomes significant after 
the abuse of certain drugs, as sulphonal and trional, and in some people 
it is excreted without obvious cause. Such persons are said to be ex¬ 
ceedingly sensitive to light upon the skin. An animal may be wholly 
unaffected by the injection of hematoporphyrin in the dark while it soon 
succumbs to a much smaller dose if maintained in the light. “Hausmann 
injected white mice with it and found 0.01 gram harmless in the dark 
while 0.002 gram will bring on acute symptoms in the light. There 
is a marked but temporary hyperemia of the ears, nose and tail, and after 
a period of great activity the animal becomes quiet, shows dyspnea and 
dies in one to three hours.” 

Such facts as these suggest a line of investigation which may give to 
light an importance in medical climatology hitherto undreamed of. 

It has already been stated that temperature takes the first rank in 
determining the physiological relations of climate. But it has long been 
clear that the feeling of heat, or “sensible temperature,” may vary widely 
from the air temperature as measured by the ordinary thermometer. 
Professor M. W. Harrington, former Chief of the U. S. Weather Bureau, 
was apparently the first to definitely point out that the sensations of 
temperature run much more nearly parallel to the readings of the wet- 
bulb than of the dry-bulb thermometer. 

Accordingly, in dry air, in which the heat of the body is carried away 
by evaporation or perspiration, the weather may be comfortable, when at 
the same air temperature in a humid locality the heat would be oppres- 


198 THE PRINCIPLES OF MEDICAL CLIMATOLOGY 


sive. Wind movement greatly enhances evaporation and the cooling effect 
of dry air. Isotherms plotted from readings of wet and dry-bulb ther¬ 
mometers, respectively, differ widely in their course, and we find a physi¬ 
cal explanation of the coolness felt on entering the shade on a summer’s 
day in arid regions. In the winter, by reason of the low humidity, little 
heat is lost to the body by conduction. Therefore, resorts in elevated 
regions tend to seem much cooler in summer and warmer in winter than 
places on the same parallel near sea level. 

Professor Cleveland Abbe points out that different individuals re¬ 
spond variously to the same physical environment, as does one and the 
same person at different times, as before and after eating. Observing 
his own sensations, with the wind blowing five miles an hour, he noted 
the following results: 


Individual Reaction to Physical Environment 


Temperature 
—Degrees F 

Relative Humidity 

Subjective State 

80 

20 

Feels fine 

40 

60 

Feels fine 

20 

80 

Weather very raw 

60 

80 

Comfortable 

80 

100 

Suffocating 


In his recent study of the influence of climatic factors on human 
efficiency in its broadest sense, Professor Huntington gives the pre¬ 
eminent place to temperature. He writes: “The law of optimum tempera¬ 
ture apparently controls the phenomena of life from the lowest activities 
of protoplasm to the highest activities of the human intellect.” 

In an essay like this it is impossible to give a detailed discussion of 
the modification of physiological functions induced at high altitudes. 
The monumental works of Paul Bert, of Mosso, and of Zuntz and his 
collaborators, together with the researches which have been cited here, 
represent the essentials of our present knowledge of the subject. 

The science and art of aviation as developed in the late War do not 
appear to have, as yet, added much to our knowledge of high altitude 
climatology. It was found necessary to subject candidates for aviation 
to elaborate tests as to the celerity and range of their physiological accom¬ 
modation to the conditions of high flying. 

Dust and Atmospheric Impurities.—Impurities in the atmosphere in 
the form of dust and noxious gases, not to speak of bacterial and other 
contaminations, have undoubtedly great, though little investigated, effect 
on human health. The lungs are the organs specifically affected. The 
solid particles inhaled, to a greater or less extent, penetrate the bronchial 
mucous membrane and are distributed thence by the lymphatics, leading 








DUST AND IMPURITIES 


199 


to a condition known as pneumonokoniosis. Fibroid changes are induced 
by irritation from the foreign particles, and considerable areas of the 
lung tissue may be replaced by solid nodules, or masses of deeply stained 
fibrous tissue. Chronic bronchitis and emphysema are the characteristic 
clinical sequences. The familiar “miners’ consumption” is anatomically 
a pulmonary fibrosis. In the lungs of a stone-cutter, forced to abandon 
his occupation on account of increasing dyspnea, the X-ray plate showed 
me dense shadows radiating from masses at the roots of the lungs, and 
involving the greater portion of the organs. There was no evidence of 
tuberculosis in this case. Lungs so affected seem to lose much of their 
normal immunity against bacterial infection. In the mining regions of 
Colorado it is not uncommon to find superb athletes suddenly succumbing 
to an intractable form of pulmonary tuberculosis. It is not improbable 
that the high mortality from pneumonia witnessed in similar districts 
is likewise associated with dust inhalation. The intimate effect of in¬ 
organic inclusions on the vital resistance of the lungs is emphasized by 
J. M. Anders, who quotes Scurfield’s observations on occupation mor¬ 
tality in Sheffield; the death rate of “grinders from phthisis is more than 
six times, and the death rate from other respiratory diseases nearly three 
times, that of the average male; while the death rate of cutlers from 
phthisis is nearly three times, and from other respiratory diseases nearly 
four times, that of the average male.” The quality of the foreign matter 
inhaled seems not to be indifferent; thus, according to Osier, coal miners 
are not especially subject to phthisis. In his experiments on dust Tyn¬ 
dall found the air exhaled toward the end of expiration to be free from 
solid particles, a fact significant of the amount of dust that must be 
retained. In manufacturing centers the smoke from burning coal, com¬ 
posed chiefly of carbonaceous particles with a considerable content of 
C0 2 and S0 2 , probably has important relations to the public health. The 
sulphurous acid is especially irritating to the respiratory mucous mem¬ 
brane. Under the action of oxygen and moisture it becomes converted 
into sulphuric acid. F. W. Schaefer calculates that there are daily dis¬ 
charged from chimneys into the air of London about 300 tons of soot, 
90,000 tons of carbon dioxid, and 2,700 tons of sulphur dioxid. 2 

These bodies are all much heavier than air and tend to settle. The 
solid particles, at least, form foci for the condensation of moisture, so 
that fogs, impregnated with the gases of combustion, are readily generated. 
Statistics show that morbidity and mortality from respiratory diseases are 
greatly increased during heavy fogs in manufacturing districts. It has 
been calculated that steel dust from the brake-shoes of moving trains for¬ 
merly permeated the air of the New York subway to the extent of one 
ton in a mile of the tunnel. 

3 The figures reported probably should be modified as the result of the application 
of smoke-consuming devices. 




200 THE PKINCIPLES OF MEDICAL CLIMATOLOGY 


White and Shuey found it extremely difficult to estimate the morbific 
influence of smoke in the air of manufacturing centers. They conclude, 
however, that “there is a general tendency of the tuberculosis death rate 
to rise as the number of smoky days in the city decreases; there is a 
general tendency for the number of deaths from pneumonia to fall as the 
number of smoky days in the city decreases.” 

It is obvious in estimating the hygienic relations of atmospheric im¬ 
purities that these should be primarily divided into two groups according to 
their solubility or insolubility in the body fluids. To the first class, 
including sulphuric acid, etc., we might perhaps expect relatively acute 
physiological response. The second class operates slowly through struc¬ 
tural alterations of the lungs manifested as more or less extensive pneu- 
monokoniosis. 

A. J. Lanza, of the National Health Council, has analyzed the data 
presented by “miners’ consumption” as it occurs among the workers in 
the Joplin mines of Missouri. The mines produce lead and zinc and 
the offending dust is siliceous from powdered flint. Miners’ consumption 
is due to the deposit in the lungs of solid particles, the irritation of which 
sets up a progressive fibrosis. The early symptoms of the disorder are a 
gradually increasing dyspnea on exertion, diminished respiratory expan¬ 
sion and pains in the chest. Many of the victims examined had been at 
work for ten to fifteen years, but it was not uncommon to detect signs 
of silicosis in those who had worked less than a year in the mines. Sooner 
or later the subject of miners’ consumption is prone to develop either 
tuberculosis or pyogenic infection of the lungs or both. Out of 720 miners 
examined by Lanza 433 had miners’ consumption and of these 103 showed 
tubercle bacilli in the sputa. The numerous X-ray pictures of the chest 
which illustrate this research are strikingly suggestive of the plates ob¬ 
tained in pulmonary tuberculosis of glandular and bronchial type with 
bilateral distribution of disease. In advanced cases the great masses of 
shadow, which are visible on the X-ray plates, can be distinguished from 
those of ordinary tuberculosis only through the lack of signs of cavitation. 

The hygienic importance of this subject must be greatly enhanced 
when, to the inorganic dust, are added putrescible substances and patho¬ 
genic microorganisms. Moreover, if the conception of atmospheric pol¬ 
lution is broadened to include not only inert suspensions, but the living 
insects which transport infectious matter, control of the purity of the 
air must banish much of the disease which now afflicts mankind. Wind 
and rain are the natural purifiers of the air, as regards accidental con¬ 
taminations. 

The Psychology of Climate.—The demonstration within the past half 
century that the law of the conservation of energy applies to the metab¬ 
olisms of the living body led to a mechanical view of vital processes which 
only incompletely represents the forces that control the human being. 


CLIMATE IN TREATMENT OF DISEASE 201 

But the mental state is still refractory to mathematical exposition, and 
practical clinicians are turning back to that viewpoint of life from which 
the mind is regarded as an ever-acting and often predominant energy in 
physiological processes. 

Madden writes: “The Stagyrite, who knew all things and treated 
of them and some others, makes excellent observations on the indispensable 
necessity of serenity of mind, hopefulness, and even cheerfulness, for 
health of soul or body.” When the change of climatic stimuli relieves 
ennui, awakens an interest in nature, or excites zest for mental effort, 
it tends to produce that cheerful serenity of which Aristotle recognized the 
value. The principles of climatic treatment are founded on psychology 
as well as physiology. 

Application of Climate to Treatment of Disease 

It would seem, at first sight, easy to determine from empirical ob¬ 
servation the climatic conditions remedial for various pathological states. 
But experience shows that benefits which had apparently been originally 
derived from the climate of some definite locality finally ceased to reward 
the seekers of health; so that factors other than those of climate were 
brought into consideration. Resorts for the tuberculous, for example, 
that once seemed salutary, have time and again developed into hotbeds of 
the disease. No fair estimate of the physiological influence of the tropics 
can he made until infections incidental to the hot zone are under sanitary 
control. In short, the causes of disease must be understood before a 
scientific application of climatic therapeutics can be hoped for. 

Again, unnecessary obscurity has been thrown around the subject of 
physiological climatology by the frequent failure to recognize that, in 
every place, many of the physical factors of climate are subject to immedi¬ 
ate artificial change, to a degree which it would require long journeys to 
realize by geographical means. Temperature, humidity, air movement, 
insolation, are largely subject to artificial regulation. 

The one disease involving consideration of climatology is tuberculosis. 

Tuberculosis.—When the pathogenic organism of tuberculosis was 
discovered, the last doubt was removed as to the reason why resorts which 
originally seemed favorable to recovery from the disease so often proved 
later to he danger spots for its acquisition. 

Pace the claims for the remedial powers of tuberculin, the years have 
yielded but one indispensable agent in the prevention and cure of tuber¬ 
culosis—the open air. It is curious how little the crudity of this clinical 
finding has been refined. We have been at a loss for definite explanation 
of the hygienic virtues of open as compared with closed air. Referring 
to a preceding discussion on the physiology of ventilation, the contention 
of Flugge seems sustained, that the morbid sensations through which we 


202 THE PKINCIPLES OF MEDICAL CLIMATOLOGY 


recognize the impurity of respired air are not due directly to acquired 
chemical properties of the air, but to the irritation of certain sensory 
nerves of the skin brought about by a rise of temperature combined with 
a high degree of relative humidity. The nerves specifically concerned 
in these sensations would seem to be those delegated to temperature sen¬ 
sations; moreover, in the clothed subject, the skin of exposed parts, the 
head, neck, hands, wrists, possibly the lining of the nasal canal, would 
seem to he of relatively paramount importance. In explaining the main¬ 
tenance of a constant body temperature under wide thermal variations of 
the air, we find no difficulty in ascribing profound alterations in metab¬ 
olism to stimuli arising in the temperature nerves of the skin. From 
the same point of view the suggestion is obvious that the sensations of 
comfort or discomfort aroused in “good” or “bad” air are but incomplete 
conscious expressions of tissue reactions which determine the molecular 
efficiency of the machine, and incidentally regulate the production of sub¬ 
stances protective against disease. While heat and humidity are of pre¬ 
dominant importance in the excitement of cutaneous sensations leading to 
feelings of well-being or ill-being, it would be a too narrow view which 
would restrict to the action of these physical agents the multifarious sen¬ 
sory impulses, largely operating through the consciousness of pleasure and 
pain, through which the metabolisms of the body are, I believe, largely 
ordered. 

Thus nature, through visual and auditory impressions, tends to 
generate an aesthetic state, which-is a potent addition to that mental at¬ 
mosphere which favors recovery from tuberculosis. 

It is worth while, in passing, to point out that the response of the 
body to the manipulations of hydrotherapy is, in large measure, hut a 
demonstration of the physiologic influence of temperature and moisture 
on cutaneous sensations. 

These reflections point to a physical basis for the known physiological 
effects of life in the open, and make it conceivable that all the advantages 
of such an environment might be secured indoors under artificial regu¬ 
lation of temperature, humidity, air movement, illumination, and other 
factors, physiologic and psychic, of the outside, climate. 

In short, the facts point to the conclusion that the “resistance powers” 
of the body, aside from those specific immunities developed in response 
to substances in the circulation, are developed as reactions to afferent 
nerve impulses, or sensory impressions, which spring for the most part 
from the cutaneous surface. 3 

The victim of pulmonary tuberculosis, thrilled with sickening chills 
along his spine, is prone to huddle over a stove in a closed chamber, or 

3 There is an analogy between the action of these trophic afferent impulses and 
that of the biochemic antigens which stimulate the tissues to produce immune bodies. 
Cf. the suggestive paper by Crile. 




CLIMATE IN TREATMENT OF DISEASE 


203 


to seek relief in a land of perpetual summer. But practical clinicians 
have found that recovery from the infection is apt to be furthered rather 
in a somewhat variable and rigorous than in an equable climate; and it 
is the general testimony from health resorts that patients commonly do 
better in winter than in summer. It is significant that the same patient 
who, left to his own devices, had dreaded a fall of air temperature below 
72° F., under proper therapeutic control learns to rejoice in the crisp, 
freezing air of a northern winter. His point of view has been so altered 
by training, that his feelings of pleasure and pain resume their normal 
function as sentinels to conserve his well-being. He breaks the vicious 
circle in which a morbid sensation led to a hurtful act (for the specific 
indications for the application of the open-air treatment in pulmonary 
tuberculosis see Volume II, Chapter XXV). 

When the conception obtained currency that the open air was the 
most salutary environment for the consumptive, a tendency was mani¬ 
fested by certain phthisiographers to estimate, as of equal therapeutic 
value, all open air, and to decry the hitherto assumed virtues of climatic 
change. While admitting that the climate of the back yard was more 
remedial for the tuberculous than the climate of the adjoining kitchen, 
they would not grant that a still greater deviation in meteorologic condi¬ 
tions to be found in distant resorts could have healing virtues in excess 
of those to be found on a city lot. This question can only be decided 
empirically; but the reason cannot but be impressed with the physiological 
facts of climate, such, for example, as the specific stimulation of the blood- 
forming organs, of tissue proteid assimilation, etc., which occur in mod¬ 
erately high altitudes. The unbiased mind must grant, at least, that 
every climatic complex operates for or against the recovery of a consump¬ 
tive in proportion as it excites conservative or destructive physiological re¬ 
actions. The impression has gained ground that a cure of tuberculosis at 
high altitudes leaves the patient especially liable to relapse, or to again 
contract the disease, on returning to lower levels. It is probable that the 
only truth behind this belief is the fact that many cases of arrested pul¬ 
monary disease can pursue a useful life only under certain favorable con¬ 
ditions. The tendency of persons returning home, after achieving arrest 
of their disease, is to abandon the hygienic methods to which they owed 
improvement. It is also true that the temperament and constitution of 
one who has harbored tuberculosis ofttimes demand the stimulating condi¬ 
tions of high altitude to maintain a feeling of well-being, which of itself 
must be a powerful aid to the resistance powers. The body is probably 
vastly more sensitive to the influence of environment and is subject to a 
wider variety of physical stimuli than we have any idea of. An experi¬ 
mental analogy for this position is offered by the exceedingly suggestive 
results obtained by Eeid Hunt, in his investigation of the “effects of 
a restricted diet and of various diets upon the resistance of animals 


204 THE PRINCIPLES OF MEDICAL CLIMATOLOGY 


to certain poisons.” He found that the resistance of some animals to 
certain poisons may be increased fortyfold by changes in diet; the con¬ 
verse effect may follow an appropriate dietary. The resistance of animals 
to the poison was directly related to certain internal secretions, particu¬ 
larly that of the thyroid gland, whose production is modified by diet. 
“Season has an important effect upon the resistance of animals to certain 
poisons; in some cases these effects seem to depend upon seasonable varia¬ 
tions in the activity of the thyroid.” 

The writer has recently been impressed with the importance of con¬ 
sidering the acid-alkali balance of the blood as a factor affecting tissue 
resistance. Where a condition of acidosis exists, as may be manifested 
by an excess of acetone in the urine, mysterious disorders may sometimes 
easily be corrected by the application of appropriate alkaline and dietetic 
treatment. There is reason to believe that the backsets to which many 
tuberculous invalids are prone without apparent cause often find their 
explanation in a recurring acidosis. 

In an essay like this only general relations of climate to special dis¬ 
eases can be touched upon. The works of Huggard, Solly, and others 
must be consulted for details. 

Anemia—Efficient operation of the blood-forming organs is a funda¬ 
mental requirement for health. Aside from the specific effect of infec¬ 
tions, the state of the blood has a direct relation to climatic environment. 
Residence in the tropics is said to induce anemia, whereas removal to an 
invigorating climate restores the blood. The work of Zuntz, Haldane, 
and others, on high altitude physiology, seems to demonstrate that the 
diminution of oxygen tension in the air specifically stimulates the 
bone marrow, and probably other sites of blood formation, to excessive 
activity. 

Therefore, even at moderate elevations of 3,000 to 5,000 feet, the red 
blood count and the hemoglobin percentage exceed those of people at sea 
level. At high altitudes health demands a proportionate increase of hemo¬ 
globin and red corpuscles. In somewhat crude clinical observations at 
Denver, one mile above sea level, I have been accustomed to find disorders 
attributable to anemia in patients whose hemoglobin percentage ranged 
as high as from 70 per cent to 85 per cent. 

Gout.—Gout and lithemic states are due to conditions of metabolism 
and circulation which are modified by climatic treatment. According to 
Huggard, “a dry, bracing climate is always most suitable.” Neverthe¬ 
less, the writer is convinced that a characteristic effect of residence in 
high altitudes, at least in the unacclimated, is a relative venous plethora. 
High venous blood-pressure, according to good authority, leads to gout. 
Newcomers in moderately high altitudes, particularly if indiscreet in 
exercise, are apt to suffer from “bilious attacks” as a phase in acclima¬ 
tization. 


CLIMATE IN TREATMENT OF DISEASE 


205 


Rheumatoid Diseases. —Painful affections of the connective tissues 
grouped under the term “rheumatoid diseases” are common in high alti¬ 
tudes ; their incidence probably bears an inverse proportion to the metabolic 
reactive power of the individual. On the contrary, acute articular rheu¬ 
matism is less frequent than at sea level. 

The writer has had intimate opportunity of studying the case of a 
man who in Denver suffers much from ill-defined pains, at times charac¬ 
terized as muscular rheumatism, and headaches which are relieved by 
salicylate of soda. These symptoms disappear on a journey to sea level 
and remain in abeyance for some weeks after his return. 

Respiratory Affections. — Catarrhal conditions and bronchitis, as a 
rule, are most favorably influenced in a climate of moderate humidity. 
Newcomers in Rocky Mountain resorts habitually complain of irritative 
symptoms, which are due to drying of the mucous membranes. 

Tuberculous laryngitis and other organic respiratory affections, though 
primarily contra-indicating dry air, not uncommonly in elevated regions 
find amelioration in the establishment of a general improvement in well¬ 
being. Theory and experience agree in the teaching that the mortality 
from lobar pneumonia increases in high altitudes. Nevertheless, prac¬ 
titioners in moderately elevated regions will agree with J. N. Hall, 
who, from a wide experience, concludes: “I believe from this study that 
the mortality of acute pneumonia is not materially affected by altitude 
until one passes beyond an elevation of 6,000 or 7,000 feet.” 

Certainly the pneumonia morbidity and mortality in Denver are not 
in excess of those for the same disease at sea level. 

One of the most curious of clinical experiences with “bronchial 
asthma * is the frequent complete relief afforded at elevations of a mile 
or so above sea level. On the contrary, the subjects of emphysema are 
not apt to do well. 

Heart Diseases. —Heart diseases are benefited or made worse in high 
altitudes, in proportion to the power of the heart to respond to excessive 
demands upon it, and thus increase its range of accommodation. 

The prescription of “mountain climbing” for chronic heart disease 
has a sound physiological basis. Nevertheless, when a physician at an 
elevated resort finds it difficult to restore a broken compensation, he desires 
above all things to see his patient transported to a lower level. 

While the body is at rest, the mechanical conditions of the circulation 
are practically identical through a wide range of elevation above the sea; 
but the demands of muscular exertion call for an increase of cardiac 
activity which is excessive in proportion to the altitude. Acclimatization, 
or training, greatly expands the limits through which the heart can ad¬ 
just itself without overstrain. 

R. H. Babcock is probably correct in his assumption that the condi¬ 
tion of mitral stenosis is one which, for mechanical reasons, especially 


206 THE PRINCIPLES OF MEDICAL CLIMATOLOGY 


contra-indicates high altitudes. Nevertheless, in Denver, for example, 
many persons with stenosis of the mitral valve live in comfort. Nervous 
affections of the heart appear to be bettered or otherwise, in high alti¬ 
tudes, according to the general reactive powers of the patients. 

There seems no reason for believing that, in patients who lead a quiet 
life, arteriosclerosis contra-indicates residence in high altitudes. How¬ 
ever, it appears that aneurism and mortality therefrom are considerably 
greater at high than at low elevations. 

Disorders of Digestion. —In the writer’s estimation, climate is indi¬ 
rectly of importance in its impress on the digestive functions through its 
effect on the metabolic and nervous systems. 

Especially in high altitudes, a “nervous dyspepsia” is apt to reflect 
imperfect adjustment to the environment; and a “bilious attack,” which 
the writer has attributed to relative venous engorgement, frequently at¬ 
tends the process of acclimatization. 

Skin Diseases. —Great importance has been attributed in the foregoing 
pages to the physiological functions of the skin. There is no organ of 
the body which comes so directly under the influence of climate as the 
skin, yet there appears to be but a meager collection of data regarding 
the subject, either in health or disease. Cases of eczema, at least in its 
acute form, are said to do badly on the seashore, and in cold, damp 
weather. Acne is also made worse on the coast, and is apt to improve in 
dry inland stations. Cases with psoriasis do better in a warm climate. 

It has been said that at high altitudes those cases do worse in which 
the skin disease depends on nervous derangement. 

Disorders of the Kidneys. —It is generally admitted that the chief 
object to be secured in the treatment of kidney disease is rest for the 
organ. The potent factors within our control include diet, muscular exer¬ 
cise, and the activities of the skin and lungs. Experience indicates that 
patients with disordered kidneys fare worst in cold, damp places of vari¬ 
able temperature. They thrive best in warm, equable, and somewhat dry 
climates. There is substantial basis for the opinion that persons with 
inflamed or degenerated kidneys are apt to fare badly at high altitudes. 
In my experience, disease contracted at an elevation is better borne than 
when imported. It is difficult to acclimatize a diseased kidney. 

The observer is impressed with the importance of the circulation in 
renal insufficiency. Clinical experience has impressed me with the belief 
that passive congestion of the kidneys is the preponderant deleterious 
factor due to the conditions of high altitude. Certain forms and stages 
of kidney disease, as of heart disease, are distinctly ameliorated by a 
judicious mode of life at a moderately high altitude. 

The Nervous System. —Special emphasis has been laid in the preced¬ 
ing pages on the purely psychic value of climatic change. The mental 
state is molded to a great degree by the reactions occurring in the various 


REFERENCES 


207 


organs, among which the nervous system is of predominant importance. 
“Climates may affect the nervous system either directly or indirectly 
through their influence on metabolism in its widest sense. Using the 
rather indefinite terms in vogue, climates may be relaxing, sedative, or 
stimulating in their influence. When nutrition is improved and a state 
of well-being secured, the qualifying term tonic may be added. Thus, 
warm, moist coasts or islands are sedative to relaxing. On ocean voyages 
or cooler coasts the prevailing influence is tonic-sedative. Inland places 
of low altitudes are usually simply tonic in effect. Elevated inland regions 
are stimulating-tonic or simply stimulating.” 

It has been made obvious that the physiological influence of high 
altitudes tends to increase the chemical activity of certain vital tissues. 
At moderate elevations, 4,000 to 6,000 feet, laying on of proteid tissue, 
building up of the organs, and improvement in their efficiency tend to 
occur. With further increase of elevation kataholic processes gain ascen¬ 
dancy, and it is as if the machine suffered from internal friction. It 
cannot be too strongly emphasized that physiological adjustment to lowered 
barometric pressure requires time and rest. Imprudence in exercise on 
the part of newcomers is prone to turn a sojourn which might have been 
salutary into a period of nervous overstrain. Constitution and tempera¬ 
ment determine, to an extraordinary degree, the fitness of people for 
residence in elevated regions. Persons of phlegmatic disposition, or those 
who are nervous from malnutrition or overwork, are apt to do well at high 
altitudes. The hysterical and those with inherent nervous temperaments 
often find their disorders accentuated. Nevertheless, the medical observer 
is often astonished at the development of nervous stability in patients 
whom, from a theoretical viewpoint, he would have advised against seeking 
a high altitude. The general belief that an occasional drop to sea level 
is necessary to the best interests of residents at high altitudes is probably 
well founded. Differences in temperament and constitution, which be¬ 
come especially conspicuous under the strain of low atmospheric pressure, 
no doubt determine, in a less sensible degree, the adaptability of people 
to other climatic conditions. 

Though we may not accept fully Major Woodruff’s dictum that in ,the 
tropics, or brilliant sunlight, fair-skinned persons always deteriorate in 
health, as compared with brunettes, it is nevertheless true that individual 
as well as racial characters determine to a degree the adaptability of 
climates to the preservation of health and the cure of disease. 

REFERENCES 

Abbe, Cleveland. Sensible Temperatures or the Curve of Comfort, U. S. 

Monthly Weather Review, xxv, 362, August, 1898. 

Air Service, Medical. Gov. Printing Office, 1919. 


208 THE PRINCIPLES OF MEDICAL CLIMATOLOGY 


Anders, J. M. Street Dust as a Factor in Spreading Disease, Tr. Am. 
Climat. Ass., xxvi, 113, 1910. 

Babcock, R. H. High Altitude and Heart Disease, Ibid., xv, 159, 1910. 

Barcroft and King. Journ. Physiol., xxxix, 374, 1910. 

Bert, Paul. La Pression Barometrique, 1878. 

Billings, Mitchell, and Bergey. Smithsonian Inst., 1895. 

Boycott and Haldane. The Effects of Low Barometric Pressures on Res¬ 
piration, Journ. Physiol., xxxvii, 359, 1908. 

Burker, et al. Ztschr. f. Biol., lxi, 379, 1913. 

Chittenden, R. H. Physiological Economy of Nutrition, 1905. 

Clark, Janet H. Physiol. Rev., ii, 285, 1922. 

Clemow, F. G. The Geography of Disease, Cambridge Univ., 1903. 

Crile, George W. Phylogenetic Association in Relation to Certain Med¬ 
ical Problems. Ether day Address, October 15, 1910, Mass. General 
Hospital. 

Ercklantz, W. Das Verhalten Kranker gegeniiber verunreinigter 
Wohnungsluft, Ztschr. f. Hyg. u. Infectionskrankn., xlix, 433, 
1905. 

Fliigge, C. Uber Luftverunreinigung, Warmestauung und Liiftung in 
geschlossenen Raumen, Ibid., 385. 

Gilbert, O. M. Differential Leukocytis at Various Altitudes, Colorado 
Med., viii, 482,1911. 

Haldane and Priestley. The Regulation of the Lung Ventilation, Journ. 
Physiol., xxxii, 225, 1905. 

Haldane and Smith. The Oxygen Tension of Arterial Blood, Ibid., xx, 
497, 1896. 

Haldane, Douglas, Henderson, and Schneider. Phil. Tr. Roy. Soc., 
cciii, 185, 1913. 

Hall, J. N. Report of Cases of Pneumonia in Colorado, Tr. Am. Climat. 
Ass., 1909. 

Hann, Julius. Handbook of Climatology, R. DeC. Ward, 1903. 

Harrington, M. W. Sensible Temperatures, Tr. Am. Climat. Ass., 1894. 

Henderson, Yandell. Fatal Apnea and the Shock Problem, Johns Hop¬ 
kins Hosp. Bull., xxi, August, 1910. Also numerous contributions 
in the Am. Journ. Physiol. 

Heymann, B. Ztschr. f. Hyg. u. Infectionskrankn., xlix, 388, 
1905. 

Hill, Leonard. Atmospheric Pressure, Recent Advances in Physiology 
and Biochemistry, 1906. 

Hill, Rowlands, and Walker. Journ. Physiol., xli, iii, 1910. 

Hough, Theodore. The Physiological Aspects of Ventilation, Am. Journ. 
Pub. Hyg., xx, 262, 1910. 

Howell, W. H. Textbook of Physiology, 1907. 

Huggard, W. R. A Handbook of Climatic Treatment, 1906. 


REFERENCES 209, 

Humphreys, W. J. The Physics of the Air, 82, 541, Weather Bureau ed., 
1920. 

Hunt, Reid. Bull. No. 69, U. S. Hyg. Lab., June, 1910. 

Huntington, E. Civilization and Climate, Yale Univ. Press, 1915. 

Lanza, A. J. Am. Journ. Pub. Health, vi, 674, 1916. 

Lee, F. S., and Scott, E. L. Am. Journ. Physiol., xl, 486, 1916. 

Loevenhart. Arch. Int. Med., xv, 1059, 1915; also Dallwig, Rolls and 
Loevenhart, Am. Journ. Physiol., xxxix, 77, 1915. 

Lusk, Graham. Science of Nutrition, 114, 1917. 

Madden, T. M. On Change of Climate, etc., 3d ed., London, 1874. 

Manson, Marsden. The Evolution of Climates, Science, 571, Nov. 17, 
1922. 

Mayer, Edgar. Am. Rev. Tuberculosis, v, 75, 835, 1921. 

Meltzer, S. J. Factors of Safety in Animal Structure and Animal 
Economy, Journ. Am. Med. Ass., February 23, 1907. 

Moore, W. L. Descriptive Meteorology, 1911. 

-The Influence of Forests on Climate and on Floods, Government 

Printing Office, 1910. Also discussion, Tr. Am. Climat. Ass., xxvi, 
46, 1910. 

Mosso, A. Life of Man on the High Alps, translated by E. L. Kiesow, 
1898. 

Osier, Wm. Practice of Medicine, 632, 1906. 

Paterson, Marcus S. Autoinoculation in Pulmonary Tuberculosis, Lon¬ 
don, 1911. 

Paul, L. Die Wirkungen der Luft bewohnter Raume, Ztschr. f. Hyg. u. 
Infectionskrankn., xlix, 405, 1905. 

Pemhrey, M. S. Animal Heat, in Schafer’s Physiology, i, 1898. 

Phillips, W. F. R. Article on Climate in Buck’s Ref. Handb. Med. Sc., 
iii, 1901. 

Ranke, K. E. Uber dem Begriff, Klima, Mlinchen. med. Wchnschr., No. 
52, 2111, 1901. 

Rollier. Die Heliotherapie der Tuberkulose, 1913. 

Rosenau and Amoss. Organic Matter in Expired Breath, Journ. Med. 
Research, xxv, 35, September, 1911. 

Schaefer, F. W. The Contamination of the Air of Our Cities with Sul¬ 
phur Dioxid, the Cause of Respiratory Disease, Boston Med. & 
Surg. Journ., 106, July 25, 1907. 

Sewall. Arch. Int. Med., xiii, 856, 1914. 

-Interstate Med. Journ., xxiii, 23, 1916. 

-Musser and Kelly’s Practical Treatment, i, 586, 1911. 

Sewall and Childs. The Interpretation of X-ray Pictures as an Aid to the 
Early Diagnosis of Thoracic Aneurysm, Am. Journ. Med. Sc., Sep¬ 
tember, 1907. 

Solly, S. E. Medical Climatology, 62, 1897. 





210 THE PRINCIPLES OF MEDICAL CLIMATOLOGY 


Tyndall. Floating Matter of the Air. 

Ward, R. DeC. Climate, Considered Especially in Relation to Man, 
New York, 1908. 

Webb, G. B. Jonrn. Outdoor Life, xii, 277, 1915. 

Webb and Williams. Some Hematological Studies in Tuberculosis, Tr. 
5th Annual Meeting of Nat. Ass. Study and Prevention of Tuber¬ 
culosis. 

Webb, Williams, and Basinger. Artificial Lymphocytosis in Tuberculo¬ 
sis, Ibid., 6th Annual Meeting. 

White and Shuey. Tr. Am. Climat. Ass., xxix, 233, 1913. 

Woodruff, C. E. Effect of Tropical Life on White Men; The Neuras¬ 
thenic State Caused by White Light, N. Y. Med. Record, lxviii, 1005, 

1905. 

Zuntz, Loewy, Muller, and Caspari. Hohenklima und Bergwanderungen, 

1906. Reviewed by Sewall, Int. Clin., Series 16, iv, 1906. 


CHAPTER V 


PHYSIOTHERAPY, MASSAGE, EXERCISE 
Harry Eaton Stewart 

PHYSIOTHERAPY 

Before considering in detail the different phases of physiotherapy and 
the proper method of blending them in the treatment of various diseases 
and injuries, a brief survey of the subject, its scope and relationship to 
general medicine and surgical practice is in order. Physical agents have 
been employed therapeutically since the earliest days of medicine. Heat, 
exercise, massage, sunlight and water applied to the body were the first- 
physical agents to he used. Galvanic and faradic electricity have been 
used for about a century. Static electricity has been employed nearly 
half as long, while the sinusoidal and high-frequency currents are of 
recent date. The amazing speed attained in the recent development of sci¬ 
entific medicine has been more than matched in the field of physiotherapy 
by the development of modern apparatus, experimentation and refine¬ 
ments in technic. The advance in the scientific application of physical 
therapeutics in the last decade is perhaps greater than that which was 
made up to that time. The pioneers who worked in the field of electro¬ 
therapy, hydrotherapy or massage and exercise laid the foundation for the 
modem use of physiotherapy, forming the basis for the millions of treat¬ 
ments given to the ex-service men. In the medical corps of the various 
armies during the Great War, for the first time in the history of medicine 
a large number of regularly trained physicians devoted their entire time 
and attention to all branches of physiotherapy. 

In the American army we were able to institute a department of 
physiotherapy which functioned in sixty-two different hospitals and was 
comprised of over a hundred physicians and twelve hundred reconstruc¬ 
tion aides. The personal backing of the Surgeon-General, and the organ¬ 
ization of a department of his office under Lieutenant Colonel Frank B. 
Granger, of Boston, brought together a personnel and equipment the like 
of which had never before existed. From 1918 to the end of 1922, mil¬ 
lions of physiotherapy treatments were given to the service and ex- 

211 



212 PHYSIOTHERAPY, MASSAGE, EXERCISE 

service men by tbe medical departments of the Army, Navy, U. S. Public 
Health Service and Veterans’ Bureau. The results on the whole were 
extremely gratifying and by reason of the vast amount of data collected 
we may feel that physiotherapy is on as firm and proved a scientific 
basis as any other branch of medical practice. 

The scope for the application of this branch of therapy has rapidly 
widened until at the present time a large proportion of diseases and 
almost all types of injury are amenable to treatment by it. It cannot be 
too strongly insisted upon that, with a few minor exceptions, physiotherapy 


Fig. 1.—A Well-equipped Electrotherapy Room. 

is not a complete regime of treatment, but is an adjunct to the routine 
hygienic, medical and surgical care of the patient. Eortunately there 
are practically no contra-indications to the employment of the accepted 
methods in combination with physiotherapy in any given case. Long 
retention of fixation apparatus is perhaps the main exception. Physio¬ 
therapy is directly applied to the affected part. It requires a large 
amount of detail in the technic of its employment. The large floor space 
and special apparatus required to do the best work places a limitation 
upon the amount of physiotherapy which the general practitioner can do 
conveniently. Nevertheless, it is vitally important that he be able to 
determine those conditions in which the help of physiotherapy will lead 
to more rapid recovery on the part of his patients. A full equipment is 














PHYSIOTHERAPY 


213 


for the specialist and the hospital department of physiotherapy, both of 
which are now rapidly increasing in number. On the other hand, a great 
deal of good may be accomplished with a comparatively simple equip¬ 
ment, providing the indications and principles underlying the technic 
are thoroughly understood. Even a good piece of apparatus and the 
manufacturer’s direction as to its use are not a sufficient background for 
practice in even a single branch of physiotherapy. 

A digest of the main modalities used and indications for the employ¬ 
ment of physiotherapy will exemplify the widening scope of this branch 
of treatment. The electrical currents are employed in accordance with 
their three main effects on living tissue: first, changes in chemistry; sec¬ 
ond, mechanical action; and third, the production of heat. In the first 
division falls the straight galvanic current and we use it to rearrange the 
ions within the tissues, to drive in drug ions from without, to destroy 
tissue by their caustic concentration, and to allay nerve pain. In the 
second group are found the interrupted and wave galvanic and sinusoidal 
currents used for the contraction of muscle completely or partially de¬ 
prived of its nerve supply, and to stimulate other functions by muscular 
contraction. 

Faradism is used to restore the tone of underfunctioning muscles whose 
nerve supply is normal. Static electricity, in the form of the Morton wave, 
sparks and effluve, is employed to produce mass or local tissue contrac¬ 
tion for glandular stimulation or the removal of lymphatic stasis, and 
to alleviate pain due to the pressure of such stasis. The high fre¬ 
quency currents of Oudin and Tesla produce superficial and, to a certain 
degree, deep heat, relieve pain and stimulate metabolism, or destroy by 
fulguration when localized at a needle point. Diathermy , which is one 
of the most powerful agents in all the field of medicine, creates an in¬ 
tense deep-seated heat localized at will, with a subsequent active hyperemia 
which greatly reduces repair time and aids in the resistance to localized 
infection. Its general effect in lowering hypertension, decreasing pain 
and promoting general and local metabolism is also made use of. 

j Radiant light and heat stimulate the circulation, relieve pain, and 
promote repair. 

Ultraviolet light has both a local and general effect. Locally it is 
one of the most powerful of antiseptics with no effect upon the host other 
than the destruction, in strong doses, of superficial epithelium. Most 
localized infections yield readily to its application in their early stages. 
In moderate amounts it is a very powerful stimulant to skin cell growth 
and is indicated in slowly healing wounds and ulcers of the skin. Gen¬ 
erally, it is the same tonic to the body that sunlight is; enriching the 
hemoglobin and the fighting property of the blood, increasing metabolism 
and inducing sleep. 

Exercise and massage develop the body and its nervous coordinations, 


214 


PHYSIOTHERAPY, MASSAGE, EXERCISE 

stimulate metabolism, defer tissue deterioration in middle life, aid cir¬ 
culation and help to prevent and reduce deformity. 

Hydrotherapy may be used to induce reflexly both stimulation and 
sedation of the nervous system and obtain both local and general changes 
in the circulation. 

The time when the term physiotherapy meant “baking and massage” is 
over, so is the real usefulness of an assistant whose methods are limited 
to these two means. 

Requirements for Hospital and Clinical Departments of 
Physiotherapy 

The government hospital department of physiotherapy has served as a 
model for a. number of such departments recently established in civilian 
general hospitals. 

Personnel.—The type of young woman who became the reconstruction 
aide of the war and post-war days had, as a rule, normal school, college 
or nursing training and received intensive courses in all branches of physio¬ 
therapy. There are several schools of physiotherapy graduating well- 
trained aides and they are becoming available in increasing numbers. 
There should be one aide for each four to eight nurses, depending on the 
type of cases handled. 

Floor Space.—A great deal of work can be done in a relatively small 
space if it is properly arranged. There should be many wall plugs, 
divided into several separate circuits. The intake wiring and fuses should 
be very heavy. If the tables (or cubicles) are arranged parallel, with 
four feet between them and the side wall, much of the apparatus may be 
conveniently shifted to the various tables or stalls. All circuits should 
be numbered in the fuse boxes to facilitate quick replacement of fuses 
when blown out. 

Apparatus.—A small department for a hospital of one hundred beds 
would require at least the following apparatus: eight treatment tables; 
two sets of pulley weights; one galvanic control; one faradic coil; one 
sinusoidal machine; one air-cooled ultraviolet lamp with a few quartz 
applicators for local work; four small portable or two 1500 candle-power 
radiant lights; two portable and two stationary high frequency machines. 
In a two-hundred-bed hospital, this equipment should be doubled except 
that a water-cooled ultraviolet lamp, instead of a second air-cooled should 
be added, together with a motor vibrator, static machine and paraffin bath. 
Care should be taken to state the type of current, frequency and voltage 
in ordering machines. In larger hospitals and those devoted to special 
types of cases, this equipment would have to be greatly modified. A cor¬ 
rective gymnastic room and hydrotherapy plant are most useful where it 
is possible to install them. 


PHYSIOTHERAPY 


215 


Post-war Reconstruction. —The writer, after his work as assistant 
director of physiotherapy of the army section, organized the section of 
physiotherapy in the Bureau of the United States Public Health Service, 
which took over the care of the disabled ex-service men. This work has 
grown during the last four years to a magnitude equaling that done by 
the Army Medical Corps and has now been transferred to the Veterans’ 
Bureau. In the meantime the Public Health Service has continued and 
extended this work among its own Marine Hospitals, and the Navy has 
also established this branch of its medical service on a good basis. The 
longer these hospital departments have functioned, the more invaluable 
have they proved themselves. With the ex-service, men the work, now 
largely with chronic diseases, has fallen into three main types. First, 
the neuropsychiatric cases, which include peripheral nerve regeneration, 
traumatic psychoses of various types, and a wide variety of other con¬ 
ditions. All types of physiotherapy are employed in the treatment, but 
hydrotherapy takes a more prominent place than it does in the general 
hospital. Second, the tuberculous group, often complicated by war wounds 
and various other conditions. With this class of cases, ultraviolet light 
is of great importance although all methods are employed. The third 
type is the general medical and surgical group which requires a well- 
rounded application of physiotherapy. It is certain from the results 
obtained that physiotherapy will have an increasing role in the treat¬ 
ment of these conditions until the chapter is closed. Those in charge of 
departments in general and special hospitals can learn much from what 
has been accomplished by the adequate, thorough and persistent application 
of physiotherapy to a wide range of conditions under government super¬ 
vision. 

Industrial Accidents. —There have lately been established, in rapidly 
increasing numbers, clinics and hospitals devoted entirely to the physical 
rehabilitation of the injured workman. Physiotherapy and prescribed 
occupational therapy with vocational training form the backbone of their 
work. It is a matter of great economic importance to the worker, his 
family, his employer and the compensation insurance companies that he 
be returned to functional efficiency and full earning power at the earliest 
possible moment. Once the initial surgical care has been properly per¬ 
formed, main dependence for this early return of function must be placed 
on physiotherapy. Nothing else can be substituted for it. The recovery 
time in fractures can be reduced by about one-third. In cases of sprains 
and bruises, an even greater reduction in recovery time is possible. The 
cost of special treatment or of maintaining a department of physiotherapy 
is much less, from an economic standpoint alone, than is the payment of 
compensation through an unnecessarily long period of disability. There 
is no question that in this particular field physiotherapy will make one 
of its most valuable contributions to medicine. 


216 PHYSIOTHERAPY, MASSAGE, EXERCISE 

Athletic Injuries. —It has been conclusively demonstrated in the treat¬ 
ment of the injured athletes of some of the larger university teams during 
the last three years that physiotherapy properly used greatly cuts down 
the time of disability during which athletes have lost their usefulness to 
the team. The sprains, strains and muscle bruises which make up a large 
part of athletic injuries are especially amenable to physiotherapeutic 
treatment. The danger of permanent disability or recurrent injury 
through chronic weakness is markedly lessened. The prescribing of the 
treatment must be in the hands of the team physician and not the athletic 
trainer. 

General Hospital Practice. —It has been said that “no hospital can 
call itself modern in these days unless it has a good department of physio¬ 
therapy/ 7 That statement is subscribed to by practically all physicians 
and surgeons who have had the opportunity to watch such a department 
function. Occasionally, in the government services, the medical officer 
in charge of a hospital has been reluctant to assign the space and under¬ 
take the expenses incident to the establishment of a hospital department. 
Practically without exception those medical officers have become en¬ 
thusiastic in their support of their physiotherapy department. They have 
come to the conclusion that the average number of hospital days has been 
sufficiently reduced in the case of patients treated by physiotherapy to 
more than compensate for the expense and the space necessitated by its 
installation. 

Medical School Curriculum. —Only a few of our medical schools have 
as yet placed physiotherapy in the course of study. A reviewer of the 
Journal of the American Medical Association in a recent comment on a 
new text on this subject stated, “The subjects are generally studied in¬ 
adequately or not at all in medical schools. One of the excuses given 
for the neglect of these important topics in the medical school has been 
the lack of a suitable textbook. Unfortunately the real cause for the 
neglect of physiotherapy is the ignorance of the framers of medical school 
curriculums regarding it. As the students of the present become the 
curriculum makers of the future, we have here a vicious circle/ 7 

There are many well-qualified teachers now available and there is 
no longer adequate excuse for the neglect which the medical schools have 
shown in instructing their students in this important subject. 

The object of the section termed Applied Physiotherapy (Chapter 
XII) is to show the proper blending of the various modalities described 
in Chapters V to XI in the treatment of those phases of injury and 
disease in which these measures have proved of value. Very little has 
appeared so far in the literature on the use of more than a single type 
of physiotherapy in a given condition. The author of a textbook on 
Hydrotherapy treats of the application of that phase alone and gives an 
appended list of pathological conditions in which it is useful. The same 


MASSAGE 


217 


is true of authors of texts on Exercise and Massage or upon Electrotherapy. 
It is felt that an outline of the properly combined use of the different 
types of physiotherapy indicated in any given condition will prove of 
great value. It must be thoroughly understood that the writer is dealing 
with physiotherapy as an adjunct to the indicated hygienic, medical or 
surgical procedures in every given case, and it is taken for granted that 
these measures have been determined upon and instituted in conjunction 
with the physical therapeutic measures here outlined. In the more com¬ 
mon conditions met with, an ideal treatment, presupposing the use of a 
complete equipment, will he considered and, where possible, a simplified 
technic will be added which requires but little apparatus. 

Through choice, a large number of conditions in which types of physio¬ 
therapy have been used, but where the results have not been uniformly 
of value, have been omitted. Success in using physiotherapy is dependent 
as much upon a thorough detailed knowledge of the proper technic as it 
is in any other phase of therapy. The work and research now being done 
in the field will undoubtedly rapidly widen the known indications for 
its use. The physician and surgeon now have at hand an adjunct of in¬ 
creasing usefulness in the field of therapeutics, and one which will richly 
repay them for time spent in careful investigation. 


MASSAGE 

Definition. —Massage is the scientific manipulation of the soft tissues 
of the living body for therapeutic purposes. It modifies both the physi¬ 
ological and pathological tissue processes by mechanical means. 

History. —Many centuries before the Christian era, the Chinese were 
probably the first to use massage. In India, Japan and Arabia, the use 
of this method of treatment is very old. It was used for therapeutic pur¬ 
poses by the Greeks and testimony as to its value in certain conditions 
can be found in the writings of Hippocrates. The Romans employed mas¬ 
sage in connection with their baths. Galen used it with the gladiators in 
preparing them for combat. 

Pare, in the sixteenth century, recommended massage and passive 
motion in disabled joints and many other conditions. A little over a cen¬ 
tury ago the French extended its use and gave their terms to the various 
movements into which the manipulations became divided. To Grovesnor 
of England, Balfour of Scotland and Ling of Sweden, we owe the placing 
of massage upon a scientific basis. Particularly are we indebted to Ling, 
his son and successors in the Royal Central Institute of Stockholm for 
the proper correlation of exercise with massage. During the last half 
of the nineteenth century, Mezger of Amsterdam, Weir Mitchell and J. H. 
Kellogg of America were instrumental in gaining the recognition of the 


218 


PHYSIOTHERAPY, MASSAGE, EXERCISE 


profession to the value of massage, until at present the wide therapeutic 
indications for massage have general recognition. 

The widening scope of other phases of physical therapeutics has 
clearly demonstrated the fact that there are other and better means of 
fulfilling some of the indications for which massage has been formerly 
used. However, for certain results no substitute will serve as well. 

In modern therapeutics, massage is usually blended with other types of 
physiotherapy and takes an important place in such combinations of 
treatments. 



Fig. 2. —Effleurage of the Forearm. ( Courtesy Paul B. Hoeber.) 


General Considerations.— The physician with his background of 
anatomy, physiology and pathology may acquire sufficient knowledge to 
prescribe massage intelligently in a very short time. The amount of prac¬ 
tice necessary for him actually to give a treatment with reasonable skill 
is not great. While few physicians are able personally to do their treat¬ 
ment work, the knowledge acquired in learning how to do it well will 
be invaluable in estimating how skillfully their prescriptions are carried 
out. The rubbing of the Turkish bath attendant and the manipulations 
of the athletic team rubber” have very little relation to scientific mas- 
sage, nor is the efficiency of the average treatment in direct proportion 
to the amount of physical energy that the masseur expends upon the 
patient. 

There are three distinct schools of massage, the English, Swedish and 




MASSAGE 


219 


Hoffa. The best work is done by those whose knowledge of anatomy, 
physiology and pathology is greatest, and who have made a careful study 
of all methods, blending the best of each and evolving their own per¬ 
sonal technic. It is well to watch carefully one who claims to be pro¬ 
ficient in any one of these schools. The attitude of the masseur should 
be sympathetic and friendly, yet detached and businesslike, for it is only 
through absolute confidence on the part of the patient that he is able to 
relax completely and best results be obtained. No jewelry should be 
worn on the hands of the operator, nor any sleeves below the elbow. 
Only the part of the patient’s body under treatment should be exposed. 
The part being massaged should be supported. The temperature of the 
rooms should be from 70° to 75° F. Where much massage is to be done, 
it is necessary to have an especially constructed table which should be 
about 2 feet wide and 32 to 36 inches high. A solid table covered with 
a good mattress is to he preferred to springs of any kind. In our army the 
reconstruction aides very often discovered, during their massage, the 
presence of foreign bodies and changes in the condition of the parts. These 
they were encouraged to report to the physician, hut changes in technic 
of treatment were not and should not be allowed without the physician’s 
orders. It must he remembered that we are dealing with a potent agency 
when we are applying massage to patients. The physician should no more 
order massage for a given condition without stating the type and the 
amount than he should order drugs without stating the kind and the 
dosage. Massage may he used for diametrically opposite purposes, to 
soothe or to stimulate, and must, therefore, he minutely prescribed if the 
treatment is to be beneficial. 

Most masseurs use some kind of a lubricant on the hands. Cold cream, 
cocoa butter, vaselin and olive oil have all been used for this purpose. 
The first is perhaps the best for general use, and should be removed from 
the skin with alcohol. There is a general tendency to use too much 
lubrication. It is impossible to produce good friction with any lubricant. 
Powder is being used more extensively and is preferred by many. The 
use of stimulating liniments or icthyol in any form for counterirritation 
is of no use to the patient, and it may seriously affect the hands of the 
operator. 

The length of time of a treatment depends on many factors. A local 
treatment of from five to ten minutes is sufficient as a rule when combined 
with other physical agents. In the treatment of a single part, where 
massage alone is used, fifteen to twenty minutes may be employed. In a 
general treatment, which should take about an hour, the relative number 
of minutes given each part should be approximately as follows: legs, fif¬ 
teen; arms, ten; chest, five; abdomen, fifteen; back, fifteen. Such gen¬ 
eral treatments should be given not sooner than an hour after eating, and 
a short period of rest following the treatment is advisable. The severity 



220 PHYSIOTHERAPY, MASSAGE, EXERCISE 

of the treatment and the relative proportion of time given to the differ¬ 
ent types of manipulation are determined by the object in mind. 

Types of Movements. —There are five main movements used in 
massage: 

1. Effleurage or stroking. 

2. Petrissage (pinching or kneading). 


Fig. 3. —Petrissage of Caef Muscle. (Courtesy Paul B. Hoeber.) 

3. Tapotement (hacking, slapping or percussion). 

4. Friction. 

5. Vibration. 

Effleurage or stroking may be done by the entire palmar surface of 
both hands, used simultaneously or alternately. In stroking medium-sized 
surfaces, such as the arm or the lower leg, the fingers and inner surface of 
the thumbs are used with a firm hut flexible grasp, which accommodates 
itself to changes in the contour of the part. In still smaller surfaces like 
the Achilles’ tendon, the thumb and first finger only may be used. Be¬ 
tween the interossei on the back of the hand, the tips of three fingers, 
or the tips of the thumbs are used also in both straight and spiral stroking 
of the fingers or toes. All stroking is done slowly and, with the excep¬ 
tion of the special technic for amputation stumps, later to he described, 




MASSAGE 


221 


in the direction of the venous or lymphatic flow. It is done lightly for 
superficial effect, more deeply to affect the circulation of underlying tis¬ 
sues. Where possible the hand or fingers are kept in contact with the 
part, returning very lightly to the starting point of the stroke. The 
pressure is usually slightly greater in the mid part of the stroke than at 
the beginning and end of it. Effleurage should be slowly done, perhaps 
twenty to thirty strokes per minute on the average. It is a general rule 
for the movement to be carried beyond the next proximal joint. It is of 
great importance to train the hands to equal skill so that they may be 
used alternately or simultaneously with the same deft touch. In full- 
hand stroking, the fingers should be held lightly together. 

The physiological effects of effleurage are perfectly definite. In light 
stroking the sensitivity of cutaneous nerve endings is lessened, there is 
a slight diminution in the skin circulation, and diminished activity of 
the skin glands. In deeper stroking the sedative effect is not as marked. 
There is a slight increase of the skin circulation and activity of its glands, 
and a marked effect on the returning circulation in the veins and lym¬ 
phatics. This aids in the removal of extravasated blood and lymph, and 
accumulated fatigue products. 

Petrissage (pinching or kneading) is perhaps the most valuable move¬ 
ment of massage, and should, therefore, be thoroughly mastered. Like 
effleurage the operator uses a portion of the hand comparable to the size 
of the tissues to be kneaded. On the muscles of the hands and face, the 
tips of the thumbs and first and second fingers are used for picking up, 
rolling and twisting the finer muscles. In working on a single finger 
or toe, use the tip of the thumb and first finger of one hand, one placed 
laterally, the other anteroposteriorly. In muscle groups the size of those 
in the arm, the grasping is done with the entire surface of the fingers and 
thumbs, mainly by flexion of metacarpophalangeal joints. In grasping 
larger muscle masses the entire surface of both hands is used parallel and 
the muscle fibers grasped transversely. In many regions, particularly on 
the back, the muscles are rolled and kneaded against the bone. In the 
arm and lower leg the muscle groups are grasped between the thumb 
and fingers, starting distally with alternate grasping and relaxing, and 
working in a proximal direction. Skillful operators often develop a 
slight twisting movement with the hands which is an aid in thorough 
kneading. On the abdomen, where we are unable to pick out the various 
muscle layers, the kneading is done in concentric circles, deeply enough 
to reach lower muscle layers. In the gluteal region there is considerable 
dense fascia and the kneading should be deep enough to reach the muscle 
groups. 

The physiological effect of petrissage is to stimulate both motor and sen¬ 
sory nerve endings, increasing muscle tone in proportion to the vigor of 
the treatment within reasonable limits of time. Fatigue and toxic prod- 


222 


PHYSIOTHERAPY, MASSAGE, EXERCISE 


nets are mechanically removed, together with extravasted blood and lymph. 
The capillary circulation is made both more rapid and greater in volume, 
and the venous and lymphatic circulation markedly quickened. This pro¬ 
cedure is contra-indicated in conditions of muscular hypertension and 
spasticity, and should be done lightly with a minimum length of time 
in muscles having a deficient motor innervation. This stimulating effect 
on the general metabolism of muscle tissue is similar to, but not as ef¬ 
ficient as, that obtained by active exercise. It can be used as a sub¬ 
stitute for such exercise where muscle contraction would displace the 
fragments of fractures or bring strain on torn ligaments. 

Tapotement includes slapping, cupping, hacking and percussion. 

Slapping should be performed with the palmar surface of the fingers, 
by quick, light, alternate strokes, wrist relaxed, and the fingers or whole 
hands immediately rebounding from the skin surface. At no time should 
the stroke be heavy or the hand remain upon the skin. By this technic 
the sensory nerve endings are acutely stimulated, the superficial capil¬ 
laries widely dilated, and there is a reflex general stimulation produced 
on the entire nervous system. 

Cupping is done by the hands, with fingers and thumbs held tightly 
adducted and with a slight flexion at the metacarpophalangeal joints. The 
blow is somewhat heavier and, while not remaining on the skin, it has not 
the instantaneous rebound of proper slapping. The effect of cupping 
is somewhat more intense and deep seated than that of slapping, but 
accomplishes much the same results. 

Hacking may be given lightly or very heavily, depending upon the 
manner in which the hands are held, and the vigor of the blow. In both 
types, blows are struck with ulnar side of the hand, and little finger. 
The movement is performed by rapid alternating adduction of the wrist 
joints, coupled with slight supination of the forearms. In light hacking, 
the fingers are relaxed and slightly separated and strike the body; the 
little finger first and the others in succession. The blows alternate with 
extreme rapidity and with a rebounding character, resembling that de¬ 
scribed for slapping. This movement is easier to acquire if the elbows 
are semiflexed and held somewhat out from the body. It is one of the 
most difficult movements in which to obtain skill and necessitates con¬ 
siderable practice. In heavy hacking the fingers are held in adduction 
and rigid, the wrist more rigid, the blows given more heavily and slowly. 
The therapeutic indications for the employment of hacking are: the relief 
of muscle spasm of local toxic or traumatic origin, especially in the chronic 
stage; the breaking up of organized exudates within the tissues; the 
vigorous stimulation of the circulation in large and deep-lying muscle 
masses, with consequent stimulation of the metabolic changes within them. 

Another method of hacking, sometimes termed beating, may be em¬ 
ployed in dense tissues, such as the gluteal region. In this type, the fists 


MASSAGE 


223 


are tightly clenched and the body hit with the dorsal surface of the second 
phalanges of the fingers, by a combination of extension of the elbow, and 
flexion of the wrist. The physiological effect would he the same as that 
of heavy hacking. 

Percussion may he done lightly by striking the hack of the index 
finger, distal joint, with the index finger of the right hand in exactly 
the same way that it is employed in physical diagnosis. For heavier 
effect the finger or fingers of one hand may he struck by the ulnar side of 
the clenched fist. A light, slow, rhythmic percussion is soothing in its 
effect upon nerves lying within the area reached, and, conversely, heavier 
percussion is stimulating to them. To a certain extent the viscera supplied 
by spinal nerves may be effected by percussion along the spine in the 
region from which they are innervated. A similar effect may be secured 
at the point where peripheral nerves exit through certain foramina. 

Friction is given by the use of the tips of the fingers and thumbs or 
the thumbs alone, placing them on the skin and moving the skin over the 
subcutaneous tissue, with varying degrees of pressure. The movements are 
nearly always circular in type and, as before stated, no lubricant should be 
used, for this causes the fingers to slip on the skin and makes good fric¬ 
tion impossible. In small areas, such as the hands and wrist, the thumbs 
and fingers may he used simultaneously with opposed grasp, while on 
large flat surfaces it is more convenient to use the thumbs with their pulps, 
describing opposite small circles. On small joints, such as those of the 
phalanges, the thumb and one finger of both hands may be used simul¬ 
taneously. When a sufficient number of frictions, that is, six to twelve, 
are performed on an area, the fingers or thumbs are raised and placed 
in a new position, and the procedure repeated until the entire area to he 
affected has been covered. The indications for the use of frictions are 
to break down adhesions, soften scar tissue, remove extravasated ma¬ 
terial from around joints and tendons and to reduce soft, exuberant callus. 
In moderately large swellings, the movement should be first around the 
periphery and then toward the center. 

Vibration is accomplished, as a rule, by the application of one or more 
finger tips to the skin, although the palm of the hand or a portion of the 
clenched fist may also be used. A rapid tremor is effected by the action 
of the muscles of the entire arm to the shoulder joint. The effects pro¬ 
duced resemble those of percussion, and are used for practically the same 
purposes. Prolonged light vibration will effect a numbing of a superficial 
nerve, while powerful deep vibration will stimulate. The direct stimula¬ 
tion of the abdominal viscera is possible by applying this method to the 
abdomen. 

General Effects .—The detailed descriptions of the various movements 
given above should enable the physician to combine certain of them for 
his desired therapeutic result. 


224 PHYSIOTHERAPY, MASSAGE, EXERCISE 

General Indications. —Massage in some form is indicated in most 
inflammatory processes in their subacute or chronic stage, whether toxic 
or traumatic in origin, thus assisting in the local removal of effete ma¬ 
terial from the tissues. 

In atrophic muscle conditions, from whatever cause. 

To increase metabolism, both general and local. 

To stimulate the activity of the skin glands. 

To reduce the amount of scar tissue and callus. 

To increase the lymphatic and venous circulation. 

For sedative effect on the sensory nerves, and consequent promotion 
of sleep. 

To ascertain and aid in the removal of foreign bodies, such as fine 
shrapnel, shot or small pieces of necrotic bone in chronic cases. 

Contra-indications. —Malignant tissue, or swellings which might by 
any chance he malignant, should never he massaged until a definite diag¬ 
nosis is made. Xeither should massage be given in the following 
conditions: 

Acute inflammatory processes. 

Acute skin infections. 

Acute disease accompanied by fever. 

Acute phlebitis and thrombosis. 

Lymphangitis of local acute inflammatory conditions. 

Osteomyelitis, gastric or duodenal ulcers and marked degrees of hernia. 

General Massage—Regional Technic 

In a general body treatment the proportionate time given the various 
parts of the body has already been stated and is simply added for a com¬ 
plete treatment. There remains to be given the manner in which the 
various movements are blended in a thorough massage of the different re¬ 
gions of the body. It is customary for many masseurs to use passive move¬ 
ments in connection with massage. These joint movements are given, as 
a rule, just before the final stroking, the distal joints first, and in each 
case, if possible, the joint is moved through its entire normal range of 
motion several times. 

Passive motion belongs properly 10 me suoject of exercise, and is de¬ 
scribed more fully in that chapter. Facial and head massage is not in¬ 
cluded in the routine general treatment. 

The Arm.— Many operators begin on the nngers and hand with all 
the indicated movements, and work centrally. Some have felt that it 
is more advisable to work first on the proximal, then on the middle and 
lastly on the distal main segment of the limb, movements in each region 
being directed centrally. In this manner the lymphatic and venous cir- 


MASSAGE 


225 


dilations are depleted by natural stages. This same effect may be ob¬ 
tained by preliminary deep stroking. The stroking is carried from just 
below the elbow to over the shoulder cap, using opposite grasp of the 
anterior and posterior muscles, with moderately firm pressure. The fore¬ 
arm is manipulated in much the same way, the strokes running from just 
below the wrist joint to slightly beyond the elbow. Six or eight repeti¬ 
tions of fairly long deep slow strokes are sufficient to accomplish this 
result. We may then start, as is usual, with the fingers. 

The fingers and thumbs are worked on rapidly, covering their entire 
surface about twice with alternate pinching, starting anteroposteriorly 
and laterally, followed by spiral stroking. This is done by using the tips 
of the fingers and thumbs. The thenar and hypothenar eminences are 
petrissaged and frictioned, followed by finger-tip stroking between the 
interossei on the back of the hand. The wrist is then frictioned anteriorly 
and posteriorly. The fingers and thumbs are next rapidly flexed and ex¬ 
tended passively several times, followed by circumduction of the thumb, 
after which the wrist is moved through its full range of motion. 

Petrissage of the forearm is given by opposite grasp, with ascending 
circular kneading, the right hand slightly ahead of the left, and carried 
to the muscle origins beyond the elbow joint. If preferred, one hand can 
be used alone, the other supporting the patient’s hand. Tapotement may 
be lightly given, but is usually omitted in muscle groups as small as those 
in the forearm and arm. A few slow deep effleurage movements com¬ 
plete the work on the forearm. With the elbow semiflexed the joint is 
worked on with finger-tip friction, both anteriorly and posteriorly, fol¬ 
lowed by passive motions of flexion, extension, pronation and supination 
of the forearm. 

Petrissage of the arm is directed first upon the anterior and then upon 
the posterior muscles, with the right hand alone or the hands used parallel 
to each other. The extensors of the elbow are best reached by flexing 
the patient’s arm across his chest. This is followed by slow deep ef¬ 
fleurage, carried over the shoulder, and frictions entirely covering the 
shoulder joint. A number of long, rapid, light strokes from wrist to 
shoulder complete the massage. 

The Leg.—A few, slow, deep strokes of the thigh, leg and foot, in 
order, are first given. Then the toes are stroked singly or together. 
Thumb friction and finger stroking is done over the dorsum of the foot, 
the outer border and very thoroughly over the arch. The petrissage and 
stroking of the lower leg is aimed at picking out the tibialis anticus, 
peronei and calf muscle group and must be deeply and well done to reach 
the deeper lying and heavier posterior muscles. Passive motion of the 
toes, foot, ankle and knee are given, followed by full hand petrissage and 
deep stroking of the muscles of the thigh. Long slow stroking from foot 
to thigh completes the treament. Tapotement may be used over the calf 


220 


PHYSIOTHERAPY. MASSAGE, EXERCISE 


muscle group, in both tne anterior and posterior thigh muscles, with care¬ 
ful friction over the knee in the popliteal space. 

The Abdomen.—The general object of abdominal massage is to stimu¬ 
late peristalsis and the movement of the intestinal contents; to stimulate 
the activity of abdominal glands; to stimulate the muscles of the abdominal 
wall. The patient should be supine and have the knees raised and sup¬ 
ported to acquire proper relaxation. Where there is tenderness in the 
region of the gall-bladder or appendix, and during menstruation and preg¬ 
nancy, abdominal massage is contra-indicated. 

The palmar surface of the hand is held adducted and hyper ext ended, 
and all kneading is done in a circular manner. One hand may be used 
alone, or for deeper effect the other hand placed directly on it, increasing 
the applied pressure. It is common to start in the region of the cecum, 
performing two or three deep kneading movements, then replace the hand 
in a slightly higher position, repeating by following the course of the 
colon. To reach a proportion of the small intestine, circular kneading is 
extended in concentric circles, until the entire abdominal wall is covered. 
Gentle, springy, alternate pressure and relaxation over the liver, and ab¬ 
dominal viscera, is used for direct stimulation. For the removal of 
flatulence the whole hand may be vigorously percussed with the palm 
of the other hand, or the clenched fist over the hepatic and splenic flextures 
of the colon, and over the stomach. Gentle stroking with the hands, spread, 
starting high on the flanks and converging toward the groin, is used in 
completing the treatment. 

The Chest.—Place the thumbs at either side of the sternum and knead 
and friction toward the axilla in the first intercostal space, deeply enough 
to effect the intercostal muscles through the pectorals. Friction and knead 
the clavicular and sternal origin of the pectoral muscles. The outer half 
of the pectoralis major is thoroughly kneaded by the finger tips in the 
axilla, and the thumb over the front of the muscles, or better still by 
the finger tips of one hand above, the other below the muscles, performing 
a circular kneading. Finish with effleurage toward the shoulder tip. 

The Back.—The patient is placed prone and an effort made to relax 
completely the erector spinse muscles by placing a small pillow under the 
chest and thighs. This may be more ideally done by an adjustable ham¬ 
mock frame similar to the Bradford frame. Effleurage of the entire back 
with both hands simultaneously may be used, stroking the outer regions 
of the back upward and outward to the shoulder cap, the neck and upper 
part of the trapezius from the occiput downward and outward to the 
point of the shoulder. This is followed by strokes beginning at the neck 
and continuing downward close to the spine, allowing the hands to separate 
at the sacrum, and pass to the outer point of the hips. A series of fric¬ 
tions, both hands working simultaneously, on either side of the spine 
and parallel to it, thumbs meeting at the spinous processes, may be given 


EXEKCISE 


227 


starting from the neck and working down to the sacrum, repeated several 
times. Thorough kneading is then done, the hands placed parallel, work¬ 
ing on the muscles of the neck on one side and following the trapezius 
fibers to the shoulder, then on the opposite side followed by the super- 
spinatus, infraspinatus, rhomboids, erector spinse and other groups sep¬ 
arately. The erector spinse must he worked on deeply with the tips of 
the fingers and thumbs. Light tapotement over the heavier groups of 
muscles and down the erector spinse is added where stimulating effect is 
desired. The treatment is completed by a thorough repetition of effleurage. 

Summary 

There are certain salient facts in regard to massage and its use in 
therapeutics which it might he well to review in closing. We are not 
dealing with a single entity in massage, hut with a number of different 
manipulations upon the body, which in themselves have distinctive physi¬ 
ological effects. These differences may he further emphasized by the 
manner in which they are given, as regards skill, force, duration and repeti¬ 
tions of the movement. If the underlying principles have been made 
clear, the physician should be able to prescribe or perform suitable mas¬ 
sage, wherever the employment of any phase of it is indicated. Such 
intelligent choice of type and amount is of greater value to the patient 
than any degree of technical skill on the part of the operator. There has 
been, on the part of the profession, too great a tendency to place reliance 
upon the technical skill of masseurs, grounded in some one school or sys¬ 
tem. Increased care in the details of the prescription for massage to 
patients and its proper correlation with other phases of physiotherapy will 
greatly enhance its value in the field of therapeutics. 


EXERCISE 

Exercise is one of the fundamental body processes, and ranks with 
food, rest, elimination and respiration in the importance of its relation¬ 
ship to health. Modern civilization has modified exercise more than it 
has any other fundamental phase of human life. It will be shown that 
the efficiency of the body as a machine is, to a very large extent, dependent 
upon the efficiency of the muscular system. Every other important sys¬ 
tem in the body, nervous, glandular, respiratory, circulatory, and even 
osseous, is profoundly influenced by the activity or non-activity of the 
skeletal muscles. Too much consideration therefore cannot he given hv 
the physician to this important subject. His advice, if intelligently and 
faithfully followed, will increase the efficiency of the average individual, 
prevent illness and deformity and he has at his command a powerful 


228 PHYSIOTHERAPY, MASSAGE, EXERCISE 

therapeutic agent in the treatment of many pathological conditions, which 
may already be present. 

In professional and business life the amount of exercise taken by the 
average person is almost nil, while the skilled trades are requiring the 
management of intricate machinery rather than manual work. Both men¬ 
tal application and the use of finer muscle coordinations are a drain on 
the stored nervous energy of the body. Reasonable use of the larger muscle 
groups, on the other hand, has the effect of increasing ultimately the body’s 
reserve power. 

Physiology of Exercise. —A brief review of the more important facts 
in the physiology of exercise will tend to emphasize the far-reaching ef¬ 
fects it has throughout the body. We are too apt to consider the subject 
from the standpoint of the skeletal muscles alone. The reader is referred 
to texts, such as that of Bainbridge, for greater detail. Muscle power 
demonstrates the body’s efficiency as a machine. The active coordination 
of the entire nervous system and the cardiorespiratory system are essential 
in all vigorous exercise. Such coordination is not essential and does not 
occur in any form of passive exercise or massage. The energy for muscle 
work is developed in the muscles themselves, and they transform potential 
into kinetic energy, and then renew their store of potential power during 
rest. The liberation of energy in a working muscle is probably a non- 
oxidative process. Oxygen is necessary to replace potential energy, which 
must be obtained ultimately from the oxidation of the food brought to 
the muscles by the blood. Exercise increases the demand of muscle for 
nutrition and oxygen. During severe physical exertion, the muscles con¬ 
sume from five to ten times the amount of oxygen that they use during 
rest. To supply the oxygen, increased activity of the respiratory system 
is essential. We have the increase of heart rate and vigor of contractions, 
rise in blood-pressure, increased depth and frequency of respiration, and 
activity of the central nervous system, all these being an essential con¬ 
comitant of exercise. 

The available energy for muscular work is derived almost entirely 
from carbohydrates. Some of it comes from fats under certain condi¬ 
tions, but practically none from protein. Later, protein probably plays 
an important part in rebuilding the potential energy of the muscles. 
Lactic acid appears during muscular work,-and the hydrogen ion concen¬ 
tration is probably vital to contraction. 

The efficiency of the body , considered as a machine, is rather low. 
It varies from 20 to 33 per cent, depending on many factors, such as 
training, speed of the movement, especially in relation to the so-called 
“natural rhythm,” climate and fatigue. 

The oxygen consumption during exercise varies directly as the amount 
of work and the degree of pulmonic ventilation, other conditions being 
equal. Greater aeration of the lungs is induced by the increased hydrogen 


EXEKCISE 


229 


ion concentration in the blood passing through the respiratory center, and 
by nervous impulses of central origin .which increase the sensitivity of 
that center. 

Under normal rest conditions the output of the heart is about 3,000 
or 4,000 c.c. of blood per minute. In extreme muscular effort this amount 
may he increased to almost 20,000 c.c. Diastole is a passive process de¬ 
pending on the volume of venous return flow. During active exercise 
this return flow is augmented by the increased mechanical pressure exerted 
on the veins by the contracting muscles, and by the increased rate and 
degree.of the pumping action of the diaphragm. The physiological limit 
to the diastolic enlargement of the heart is reached when the pericardium 
is filled. 

Pulse rate acceleration is dependent upon the time it takes to fill the 
auricles. The main factor in determining the total output of the heart 
is the quality of its muscle fibers. The rate of contraction is increased 
by impulses from higher centers to the vagus center lessening the tonus 
of the heart fibers. At the same time the accelerators are stimulated. 
The maximum pulse rate is about 165 heats per minute in both trained 
and untrained individuals. The relative efficiency of their hearts depends 
on the amount of blood per heat that the contractile power of the heart 
is able to drive into the aorta. The net working-power of the heart is 
decreased, if the pulse rate is raised without increasing the total output 
per minute, or if its dilatation goes beyond the physiological limit. 

Increased local blood supply to the muscles is obtained by increased 
blood-pressure, constriction of the vessels in the splanchnic area and the 
dilatation of those within the muscles themselves. It may reach from 
six to eight times the amount of the circulation during rest. 

Oxygen is supplied to a working muscle in greatly increased amounts. 
Double the usual amount is withdrawn from the blood. The increased 
concentration of the hydrogen ion leads to more rapid dissociation of 
oxyhemoglobin, raising the oxygen tension in the blood plasma and aid¬ 
ing its passage into the muscles. The heart itself demands many times 
its usual supply of oxygen which is supplied by the coronary circulation. 

During violent exertion many parts of the body act as a unit to supply 
the requisite power. The impulses to motor activity are usually instituted 
by the motor centers of the brain. Impulses to the medulla increase the 
respiratory rate and raise the blood-pressure. Later the increased hydro¬ 
gen ion concentration helps to sustain effort. The impulses from the 
central nervous system are greatly increased under emotional stimulation 
which enables the heart to draw on its reserve power; beyond that, emo¬ 
tional stimulation has no effect. The role of the internal secretions, 
especially adrenalin, is probably small in increasing immediate working 
power. 

Training increases efficiency in many ways. It is accomplished by 


230 


PHYSIOTHERAPY, MASSAGE, EXERCISE 


a steady and gradual increase in the amount of exercise taken. Diet, 
sleep and other factors aid. The heart and the diaphragm are developed 
simultaneously with the skeletal muscles. During severe exertion the 
trained individual maintains a lower blood-pressure and pulse rate, and 
the amount of physiological dilatation of the heart is less than in the 
untrained. During rest also his pulse is slower, hut the heart’s output 
per beat is greater than in one out of training. The increase in the 
oxygen-carrying power of the blood, strength of respiratory muscles, better 
coordination of muscles and keener judgment of the degree of effort re¬ 
quired, all work to the advantage of the trained person. 

“Second wind ”—that relief from distress shown by distance run¬ 
ners after part of the race has been run—is believed to he due to a fall 
in the alveolar tension of C0 2 and a decrease in the necessary amount 
of pulmonic ventilation from a decreased hydrogen ion concentration in 
the circulatory blood. 

Fatigue is a lessened capacity for performing work accompanied by 
several subjective sensations. The feeling of fatigue and its actual pres¬ 
ence are not always the same thing. It may he general fatigue, having 
its main effect upon the central nervous system. This type is common. 
On the other hand, it may he largely local and due to a lessening of the 
sensitivity of the end-plate of the motor nerve in the muscle by accumu¬ 
lated fatigue products, or to a marked depletion of the potential energy 
within the muscle. Rest and an efficient circulation soon restore' the 
muscles to their normal or increased capacity. 

The after effects of exercise. The changes induced by exercise in 
the circulatory and respiratory apparatus quickly subside. The general 
metabolic changes in the body return to normal more slowly. Exercise 
is beneficial when it stimulates these metabolic processes in the body and 
promotes functional efficiency. Improved circulation, digestion, elimina¬ 
tion and sleep should result. It has been stated, “There is no evidence 
that in a 'perfectly healthy man even the most intense exertion produces 
any harmful effect on the heart.” It might he better to say on the 
trained heart. 

Effort syndrome —occurring during training, is diminished ability 
to perform muscular work. This phenomenon is accompanied by exag¬ 
gerated respiratory and circulatory changes during exercise, and by loss 
of appetite, poor sleep and feeling of lassitude. Athletic coaches call this 
condition “staleness.” The contractile power of the heart is lessened 
by overwork, resulting in a failure of the chain of events we have spoken 
of which supply the working muscle with an adequate supply of oxygen. 
A similar condition also occurs following the effect on the heart mus¬ 
culature of the toxins of acute and chronic infectious disease and the 
lessened cardiac tone of sedentary life. If the heart is seriously impaired, 
violent effort will he followed by pathological dilatation and other signs 


EXERCISE 


231 


of functional and organic injury. The pericardium may become enlarged 
with the heart and permanently lowered efficiency of the heart result, 
making muscular exertions either dangerous or impossible. 

Physical Education. —There is a present and growing world-wide in¬ 
terest in physical training. This is due to many factors, some of which 
are: 

The deplorable physical condition of nearly one-third of our manhood 
as revealed by that first national health census, the recent draft examina¬ 
tions for the army. 

The realization that a soldier is no stronger than his heart, or the 
muscles and ligaments of his feet and back. 

The intensified interest in athletic competition for both boys and girls. 

The fact that in becoming a city-dwelling nation, we are reducing 
beyond the limits of safety the play space of our children. 

The intensive study of industrial fatigue and its relation to efficiency. 

The fact that early physical deterioration and premature death is caus¬ 
ing the loss to the country of the services of too many of its business and 
professional men when they should still be in their prime. 

Types of Exercise. —The advice of the physician is constantly sought 
regarding the type of exercise suitable to various conditions, the possible 
dangers of athletics and how to safeguard the participant from them. 

The general practitioner cannot be expected to be familiar with all 
the phases of physical education which is becoming in itself a specialty 
of medicine. However, with an adequate knowledge of the physiology 
of exercise and of some of the conclusions arrived at by those in this 
specialty, the physician should be able to give intelligent advice to patients 
on exercise problems. 

Exercise falls largely into the following types: speed, strength, en¬ 
durance, skill and corrective. The last will be discussed under the 
heading of orthopedic and medical gymnastics. 

Exercises of speed , in which a given distance is covered in the shortest 
possible space of time, are suited to all ages up to thirty-five, provided the 
distances for children and adolescents are materially cut down. Illus¬ 
trated by sprint running, this might be a safe rule; allow up to twelve 
years, 40 yards; twelve to fifteen years, 75 to 100 yards; fifteen to 
eighteen, up to 220 yards, depending on training and condition. 

Exercises of strength, such as weight throwing, gymnastic apparatus 
work and wrestling, are those which require every ounce of one’s energy 
to perform. They are best adapted to the ages of sixteen to forty years, 
carefully graded for the immature. 

Exercises of endurance are composed largely of many relatively slow 
and rhythmical repetitions of movements easy in themselves, such as 
distance walking, running, skating, dancing and swimming and certain 
team games with long playing periods. They are suitable to any age 


J32 PHYSIOTHERAPY, MASSAGE, EXERCISE 

up to middle life, are never overdone by the child on his own initiative, 
but need careful supervision in early adolescence. 

Exercises of skill, such as golf, bowling, quoits, curling, etc., are 
applicable to any age and are especially beneficial after middle life. 

Most team sports combine several of these types and must be judged 
by their main elements. The factors of time or distance can be used to 
set a reasonable limit to the indulgence in them. 

The ideal program of physical education should include at least four 
elements without all of which no such program can be called complete. 

1. A preliminary physical and medical examination of every in¬ 
dividual who is to participate in physical activities is essential. This 
examination should ascertain the organic structure and functional power 
of the individual. Girth of forearm, upper arm and wrist are unimpor¬ 
tant, but the condition of kidneys, thyroid, heart, lungs, spine and feet 
are vital. Before exercise is resumed, a careful reexamination is essential 
after any illness or injury however slight. 

2. A carefully written prescription for special exercise should be 
given, to be carried out under trained supervision, whenever remediable 
defects are discovered. 

3. Regular systematic body-building exercise should be insisted upon 
for every one. Participation in athletics should be a special reason for 
taking this work instead of an excuse for omitting it. 

4. Athletics for all who are fit during at lea«t part of the season may 
safely be built on this foundation. There is a place at the “peak” for the 
varsity team composed of the physically fit, carefully trained and con¬ 
ditioned who may with reasonable safety be allowed to specialize in 
strenuous athletics. 

The Child.—When we changed the single house with its large yard 
to the multifamily apartment building, we cut down the play space per 
child many fold. Eormal school gymnastics and organized play under 
trained supervision can but partially compensate the child for this loss. 
The physician should back every effort to establish adequate physical 
training in the schools and to provide sufficient city playgrounds. One 
well-trained physical director is better than any number of unskilled in¬ 
structors. Competent medical examinations cannot be instituted too early 
in school life. 

The Adolescent.—This is the age where strenuous athletic games are 
indulged in. It must be remembered that rapid skeletal growth during 
this period outstrips that of the cardiovascular system. Heavy demands 
are made on the youth by development, study and social activities which 
must be reckoned with in deciding on the proper physical education 
program. 

The Boy .—The shortening of the playing periods in many games 
has added greatly to their safety. Football still has elements of danger 


EXERCISE 


233 


which cannot he guarded against, and the parents’ judgment is as good 
as the physician’s as to whether it is worth while. It teaches more things 
of value than perhaps any other game. Basketball is one of the most 
strenuous of games. Water polo and sprint swimming and wrestling are 
also very severe. Crew races over two miles in length are very taxing. 
The 440 and 880-yard runs are harder than the sprints or distance runs. 

The Girl .—A drastic change in the physical life of girls has taken 
place during the last two decades. Erom beanbags, croquet, Delsarte 
and a sporadic attempt at bicycling, they have taken up field hockey, ice 
hockey, their own and men’s basketball, baseball, swimming, association 
football and track and field athletics. This movement is no fad but is 
growing with each succeeding year. In its wake come serious problems 
for the physician, parent and educator, the proper solution of which will 
vitally affect the physical health of the nation. 

Unquestionably there are many gains to the girl from athletics. 
Courage, self-reliance, sportsmanship and the ideal of “teamwork” are 
taught. The function of the heart, lungs, muscles and the neuromuscular 
coordinations are greatly improved. These activities form, as with the 
boy, a rational outlet to superfluous energy. On the other hand, certain 
dangers are to he feared. The writer’s experience and research in this 
phase of physical education has led to the following conclusions: 

Athletics when properly controlled do not tend to make the girl less 
womanly. 

When given the same care in regard to medical examination, com¬ 
petent supervision and training, she is in no more danger from heart 
strain than is the hoy. 

The skeletal muscles are in no way attached to the pelvic outlet or 
perineum and their firm development cannot increase the difficulty of 
labor. On the contrary, the better general metabolism, stronger abdominal 
muscles and increased physical courage developed by athletics are a dis¬ 
tinct asset to the young woman at that time. 

There is no danger of organic displacement from the jumps and falls 
incident to athletics, providing the jumping pits, hurdles, etc., are prop¬ 
erly constructed and that the girl is in fine athletic condition. The tone 
of all supporting structures is improved in direct proportion to the im¬ 
provement in the tone of the skeletal muscle. 

During menstruation, light exercise, such as marching tactics, club¬ 
swinging, etc., should he kept up. Practice in certain phases of athletics, 
such as basketball goal shooting and signal plays, form for the sprint start 
and similar plays, may he used through the entire period. More vigorous 
plays and even contests may be permitted after the third day with most 
individuals. The girl should not be allowed to term this normal function 
“illness” nor, in the absence of a pathological condition, should she greatly 
modify her routine activities. Carefully followed up records of gradu- 


234 


PHYSIOTHERAPY, MASSAGE, EXERCISE 


ates of normal schools of physical training have shown menstrual and 
maternal histories better than those of the average woman. 

A committee of the British Medical Association, after a thorough in¬ 
vestigation of the subject, reported approval of field hockey, swimming, 
dancing and track athletics (they do not play basketball to any extent) 
for girls. Basketball under the “Women’s Rules” is a much less strenuous 
game than that played by “Men’s Rules,” but the trained athlete may 
play either with safety. Track and field athletics have reached the stage 
of international competition. Different events are suitable to different 
physical types. The pole vault, twelve-pound shot-put and middle-distance 
runs are very severe and should rarely be used. Distance running requires 
very prolonged careful training to be free from danger. The special 
value of this sport is that, unlike other team games, everything depends 
upon individual effort. Furthermore, it necessitates the gathering of 
every ounce of energy for one supreme effort. Many times during life 
the ability to make a quick, sure, supreme effort may result in the saving 
of life or limb. This ability is developed by track athletics almost ex¬ 
clusively. Other sports teach better the lessons of team play. 

The physician should insist, then, upon the safeguards before men¬ 
tioned, namely, preliminary and repeated medical examinations, trained 
supervision and proper equipment and conditions for the particular sport 
in question. With these provisions made and organic weakness ruled 
out, girls should be both allowed and encouraged to take up athletics. 

The Adult. —There is a very pressing need for games, recreational 
and hygienic in character, that can be played with safety and pleasure 
in spite of increased waistline and lengthening years. Golf and volley 
ball are perhaps the best of these games and are being increasingly used 
by business and professional men. Tennis, when available, is good in 
early middle life and golf to the end of one’s active career. A great deal 
of good has been done by the recent popularizing of simple setting-up 
drills to music and a very few minutes a day spent on individual body¬ 
building exercises will bring a rich reward. William Gilbert Anderson 
of Yale has emphasized the value of repeating several times daily such a 
simple procedure as straightening up fully, retracting the chin to the 
fullest extent and taking one or two deep inhalations. A simple group 
of setting-up exercises which should require not over six minutes to repeat 
four times each and which will aid materially in keeping the body in 
good condition are appended. 

Setting-up Exercises 


1. From “position”: 

a. Arms to thrust raise, forward thrust, return, lower. 
1. Arms to thrust raise, sideward thrust, return, lower. 
c. Arms to thrust raise, upward thrust, return, lower. 


EXERCISE 


235 


2. With hands on hips: 

a. Heels raise, lower. 

b. Toes raise, lower. 

c. Heels raise, knees deep bend, knees straighten, heels lower. 

3. With hands on hips: 

a. Trunk sideward right bend, raise, sideward left bend, raise. 

b. Trunk sideward right turn, sideward left turn, return. 

c. Trunk forward lower, raise, backward bend, raise. 

4. From “position”: 

a. Arms forward raise, sideward carry, forward carry, lower. 

b. Arms sideward raise, forward carry, sideward carry, lower. 

c. Arms forward raise, upward carry, forward lower, downward lower. 

d. Arms sideward raise, upward carry, sideward lower, downward lower. 

5. With hands on hips: 

a. Right knee raise, lower. 

b . Left knee raise, lower. 

c. Right knee raise, extend leg forward, knee bend, lower. 

d. Left knee raise, extend leg forward, knee bend, lower. 

6. To stride stand jump, arms sideward raise: 

a. Trunk bending, alternating right and left. 

b. Trunk turning, alternating right and left. 

7. Hands behind head. 

a. Trunk bending alternately forward and backward. 

8. Stationary running on toes with high knee raising. 

Theory of Medical and Orthopedic Gymnastics 

There are a number of factors relating to therapeutic exercise which 
have to be taken into consideration as well as the exercise itself. The 
personal and racial inheritance of the individual, his environment, special 
stage of development, nutrition, and other conditions, all modify the 
result which we are able to attain by corrective exercises. 

Types of Exercise. —We use for therapeutic purposes four types of 
exercise: 

1. Passive, those done wholly by the operator, or by the weight of 
the patient’s body, or other external force. 

2. Assistive, performed as far as possible by the patient, assisted 
by the operator. 

3. Active, the movements executed entirely by the patient. 

4. Resistive, done by the patient, opposed by friction, gravity, weights, 
the operators’ or the patients’ own physiologically opposing groups of 
muscles. 

It is known that as the muscle strengthens its belly becomes thicker 
and the entire muscle.somewhat shortened, thus making the distance be¬ 
tween its origin and insertion somewhat less. We are able to employ 
this tendency of strengthening muscle to shorten in the correction of sev¬ 
eral orthopedic defects, for instance, in a faulty forward position of the 


236 


PHYSIOTHERAPY, MASSAGE, EXERCISE 



head. In this case development of the retractors will tend to maintain 
a better position of the head. All posture braces, except when used as 
temporary expedients, such as the protection of a partially paralyzed 

muscle, have the oppo¬ 
site effect, namely, that 
of further weakening 
the muscle already be¬ 
low par. 

In practically all 
faulty attitudes, 
whether of head, shoul¬ 
ders, spine or feet, 
which are due primar¬ 
ily to defects in the 
skeleton, the following 
factors are present : 

1. Lack of balance 
in the power of physio¬ 
logically opposing 
groups of muscles. 

2. A gradual short¬ 
ening of the stronger 
shortened groups, with 
corresponding lengthen¬ 
ing and weakening of 
the opponents. W e 
should visualize the 
muscles as strong elas¬ 
tic bands under partial 

Fig. 4.—Use of Body Weight in Stretching Elbow tension. When we are 
Adhesions. (Courtesy Paul B. Hoeber.) in fine condition, active 

and constantly moving 

our joints through their normal range, this difference in elastic pull does 
not result in faulty posture or deformity. Whenever there ensues a weak¬ 
ness or total paralysis of one muscle or muscle group through nerve injury, 
the tendency for contractures to occur in the unaffected opponents is clearly 
understood and usually guarded against. Some means are taken to main¬ 
tain and increase the tone and the strength of the weakened muscles. 
These methods are taken up under the heading of peripheral nerve injury. 
It is not so well understood, however, that when there is general weakness 
from whatever cause the relative pull of the stronger muscles is greatly 
increased, which gradually tends to increase the faulty posture. This 
condition is common in chronic fatigue. 














EXERCISE 


3. Gradual lessening in the flexibility and range of motion in the 
joints moved by these muscles. 

4. A dulling of that “muscle and joint sense” which makes us aware 
of the fact that we are, 
or are not, in good pos¬ 
ture. 


To illustrate, take a 
case of round shoul¬ 
ders : 

The pectorals 
normally somewhat 
stronger than the shoul¬ 
der retractors may have 
their relative advantage 
increased by general 
fatigue or weakness. 

b. The pectorals 
become more contracted 
by the simple fact of 
the forward position 
of the shoulder, and 
the rhomboids, the tra¬ 
pezius and other shoul¬ 
der retractors are 
stretched out and weak¬ 
ened. 

c. The anterior liga¬ 
ments of the shoulder 
joint, being seldom ex- Fig. 5.—Use of Body Weight in Stretching Adhe- 
tended to their full ex- sions of Knee-joint. (Courtesy Paul B. Hoeber.) 
tent, tend to shorten. 

d. The individual feels perfectly comfortable in a slumpy position 
and finally becomes totally unaware of it, except when he may see himself 
in a mirror or be reminded of it by others. This point is well exemplified 
by the ex-service man who for months after his discharge from service 
“catches himself slumping” with decreasing frequency and finally forgets 
the matter entirely, except during a lecture on posture or an occasional 
military parade. 

Any exercise program for the treatment of postural defects must, 
therefore, contain at least one exercise or position aimed at modifying 
each one of these factors. We must strengthen the weaker groups of 
muscles, stretch those contracted, maintain and increase full flexibility 







238 PHYSIOTHERAPY, MASSAGE, EXERCISE 

and reeducate the muscle sense, while attempting to increase the general 
body tone. 

e. Lastly we must see to it that the child is built up in his general 
physique through general, bilateral exercises, play and improved hygiene. 

Before treatment for any given postural defect is instituted, the 
causes for such defect must be carefully studied and, where possible, re¬ 
moved. The special treatment for these conditions, such as affecting 
head, shoulder, spine and feet, are taken up in detail in their special 
sections. It will be found that the causes for most of these conditions 
are in general quite similar and fall into two main groups, which we 
might term the strain and the resistance. 

In the former group we have defects of hearing, vision, improperly 
constructed school seats, and the habitual unilateral methods of carrying 
burdens, especially by children, the construction of ill-fitting and im¬ 
properly applied clothing. Clothing supports and abnormal attitudes 
assumed to relieve pain have also to be considered. 

The factors, on the other side, which lower the resistance of the 
body to the strains put upon it include malnutrition, too rapid growth, 
the effects of toxins of acute and chronic disease, and the lack of normal 
healthy play and exercise. 

It is evident that if the strain is great enough even the relatively 
normal child may be deformed, while the child below par physically may 
be affected by comparatively slight habitual strains. 

The causes found in the first group mentioned should be removed 
or lessened, as far as possible, in every case of postural defect. Attention 
should be carefully directed toward any of those etiological conditions 
found in the second group which can be removed. 

It would obviously be futile to prescribe a set of severe corrective 
exercises for a child so undernourished that he is unable to carry the 
regime of study and work already imposed upon him. His burden should 
be lightened, his diet made ample, until he has sufficient physical founda¬ 
tion for special work. He should, figuratively speaking, be turned out 
into the pasture. In fact, many defects rapidly disappear when these gen¬ 
eral fundamental indications are taken care of. 

Medical gymnastics aim to improve the function of various organs 
of the body both directly and indirectly. The heart, being itself a muscle, 
may be carefully and progressively trained to improved function, except 
in those cases where organic lesions have progressed too far. Functioning 
of the nervous system may be markedly affected by reeducating the neuro¬ 
muscular coordination. In fact, with subnormal children, a marked toning 
up of even the higher mental processes has followed systematic and thor¬ 
ough training of this type. The activity of the gastro-intestinal tract 
and the glands which supply it may be favorably affected, both through 


EXERCISE 


239 


general activity and special abdominal exercises. Special respiratory 
exercises may, within reasonable limits, increase the lung capacity, tone 
up the splanchnic circulation and affect results of chronic empyema. It 
should be recalled, however, that the normal stimulation to increase respi¬ 
ration is the increase in the C0 2 , or hydrogen ion content of the blood, 
as it passes through the respiratory center in the medulla. Therefore, 
to induce deep breathing by creating the need for more oxygen in a 
normal manner is better than artificial deep breathing. A stationary run 
or vigorous gymnastic dancing steps are, therefore, better than forced 
deep respiration. 

The subject of the physiology and physiological effects of general con¬ 
ditioning exercises for the adult, and of play, gymnastics and athletics 
for the young, unquestionably lies in the field of preventive medicine. 
The points brought out in a study of these exercises have been dwelt upon 
at some length because they do not appear in medical literature to any 
great extent and are scattered throughout the writings on physical educa¬ 
tion in such a way as not to be easily available to the physician. The 
possible dangers of heart strain and other physical injuries in athletics 
are real, and yet the value of sports to the young is so great that a de¬ 
tailed study of the subject is thought worth while. The family physician 
is being called upon for decision in regard to athletic indulgence with 
increasing frequency. Medical and orthopedic gymnastics constitute a 
real and growing part of our therapeutic armamentarium. The increasing 
interest of parents and educators in these phases of treatment requires 
that the physician be adequately informed regarding them. 


CHAPTER VI 


MECHANOTHERAPY 
William V. Healey 

Historical and Introductory. —Of all therapeutic means used by man 
up to the present time, the application of exercise for the restoration of 
bodily function most nearly approaches nature’s own method of maintain¬ 
ing function. 

Just when exercise was first utilized in a therapeutic way is not 
known; certainly the earliest writings of the Chinese and Hindus indicate 
that these people advocated the use of exercise in a hygienic way. The 
Greeks, at the prime of their civilization, employed the bath and exer¬ 
cises, and wrote of these methods as a means to maintain bodily function. 
Through the Greeks the Romans learned of, and improved upon, the 
methods. Through the middle ages little advance in this subject was 
made, and, in fact, it was not until the seventeenth and eighteenth cen¬ 
turies that scientific thought was turned to exercise, and further ad¬ 
vancement made. 

Friedrich Hoffman, a German, 1780, and later Peter Hinric Ling, 
1786-1839, a Swedish gymnast, developed this subject and formulated 
specific free movements, upon which all modern systems of free exercise 
are still based. Ling’s work definitely connected exercise with massage, 
which manipulations he classed as “passive gymnastics.” He started in 
life as a fencing teacher and was attracted by the benefits derived from 
exercise, in developing the Central Institute of Gymnastics in Stockholm. 
From his writings and those of others, it would seem that he appreciated 
the application of exercise but lacked the scientific knowledge of its indi¬ 
cations or contra-indications. His work, however, with that of Metzger, 
a physician in Holland, attracted the attention of many of the well-known 
physicians of that time, and it was following the influence of these two 
men, and the investigation by scientific medical men, that medical gym¬ 
nastics found a place in the curriculum of the physicians. 

About the middle of the last century, Gustave Zander devised some 
ingenious apparatus to localize exercise to a given part and to eliminate, 
to a large extent, the gymnast who, according to the Ling system, was so 
important. These machines were so constructed that both active and 
passive movement was possible. 

240 


THERAPEUTIC EFFECTS OF EXERCISE 


241 


To-day, mechanotherapy is utilized as a department of physical thera¬ 
peutics and used in conjunction with the other physiotherapeutic means 
for the restoration of function. Its aim is to exercise systematically those 
organs forming the motor apparatus, thereby primarily improving or 
restoring their function; and secondarily improving the function of the 
other organs of the body. 

The necessity of treating this subject in conjunction with other physio¬ 
therapeutic means has been appreciated by those who did so much scientifi¬ 
cally to advance exercise as a means of treatment. During the period 
of development of this form of treatment, massage was usually used in 
conjunction with exercise, and, during the recent War, large departments 
were formed in the army hospitals of those nations engaged in the war, 
combining not only exercise and massage, but also all the other known 
physical means for the improvement or restoration of function, such as 
baths, heat in its various forms, and electricity. At the present time, 
many institutions have all of these departments correlated under a physical 
therapeutic director. This development has been quite rational, for it 
is easy to see that the enlarged or diseased portion of the body will tolerate 
active exercise better if preceded by massage, and in turn will tolerate 
massage better if preceded by one of the various forms of heat. It seems 
logical that the future development of mechanotherapy lies in its being 
further developed as a department of physical therapeutics. 

In judging the effect of exercise, one should understand the purposes 
for which exercise is usually prescribed. These are threefold: 

1. For educational purposes. 

2. For direct restoration or the improvement of function of a dis¬ 
eased or injured member of the motor apparatus. 

3. For the secondary or indirect improvement of function of those 
organs not units of the motor apparatus per se. 

It is through the combination of rest and exercise that the body is 
maintained in a state of health. Excess of either of these is not beneficial. 
Educational exercise given to school children, either in the form of gym¬ 
nastics or sports, has shown its value in increasing growth, general 
development and endurance, sufficiently well to require no lengthy ex¬ 
planation at this time. All the armies of the world have kept their soldiers 
in a state of physical fitness through the routine application of exercise. 


THERAPEUTIC EFFECTS OF EXERCISE 

We are here chiefly concerned, however, in the effect of exercise from 
a therapeutic standpoint, and will consider the effect of exercise from this 
standpoint. The units forming the motor apparatus of the body are made 


242 


MECHANOTHERAPY 


up chiefly of bone, joints, muscles and their nerve supply. It is well 
known that the ordinary physiological exercise performed in daily work 
conduces to physiological hypertrophy of muscle; thus the occupational 
development of the blacksmith or iron worker may be seen in contrast 
to the underdevelopment of the sedentary worker. It is not only that 
muscle hypertrophy is seen following exercise, the development of the 
bony structures follows directly in children at the age of one year, when 
most children begin to walk. The bones are soft and lack, at least from 
a radiographic point of view, the strength and internal structure seen in 
children who have walked for even a few months. This has been clearly 
expressed by Wolf, whose word is law on the development of bone, and 
who states that “change in the formation and function of bones, or of 
their function alone, is followed by certain definite changes in their in¬ 
ternal architecture, and equally definite secondary alterations of their 
external conformation in accordance with mathematical laws.” Con¬ 
versely, patients who have been bedridden for some time, lacking normal 
exercise, are seen to show a wasting and lack of tone in their muscles; 
and splinting of one of the extremities for even a week or two will produce 
definite atrophy of the part. This is further confirmed by radiographic 
examination where, after prolonged rest, the bones of the immobilized 
part will show the well-known atrophy of disuse. These changes are in 
all probability due, in turn, to the effect of exercise on the circulatory 
system. When a muscle contracts, the venous blood is mechanically 
pressed out of the veins in and around the muscles. As the muscle re¬ 
laxes, more venous blood is sucked into the recently compressed vessel. 
This hastens the speed with which the blood normally passes to the part, 
thereby placing a demand for more blood to the part, with a resultant 
dilatation of the arterioles in the part. Coincident with this, the lymph 
channels hasten their flow. 

Of secondary importance are the fascial coverings of the muscles which 
upon contraction and relaxation of the muscles act as a sort of com¬ 
pressor to the muscle as a whole, aiding in the compression and relaxa¬ 
tion of the vessels within. This may be seen in the neck where, in hyper¬ 
extension, the fascial sheaths compress the large external jugular veins, 
depleting them of blood. By skillfully applied exercise one may actually 
deplete one portion of the body of blood, as is so commonly seen where 
hyperemia in the head, resulting in congestive headache, is relieved by a 
rapid short walk. It must be remembered that with alteration in the 
length of muscle and fascia, which increases with active or passive exer¬ 
cise, there is a coincident change in shape in the blood-vessels of the part, 
so that in relaxation the vessel is longer and narrower, while in contrac¬ 
tion the vessel is shorter and wider. This change in shape assists in 
increasing the rapidity of the flow of blood through the part. When these 
local changes occur in the larger vessels of the body, such as the femoral 


THERAPEUTIC EFFECTS OF EXERCISE 


243 


or axillary, there is a definite demand placed upon the heart for increased 
activity. The response is an immediate increase in the heart’s rate, due 
to the increase of blood thrown into the right auricle. As the heart rids 
itself of this blood by increasing its rate and force, there is an initial 
dilatation of the larger arteries to receive it, which, as the exercise is 
increased and the blood is more evenly distributed, causes a diminution 
in the size of the artery, thereby increasing the blood-pressure. 

The products of oxidation produced by muscle activity stimulate the 
respiratory system to further work. The call of the body for further 
oxygen has not shown itself in the increased activity of the respiratory 
organs. With most general exercise, the muscles of the chest are brought 
into function, and this is further increased in the demand of the body 
for further oxygenation, and furthermore acts mechanically upon the 
heart. This call for increased oxygenation in even moderate exercise 
results in a filling of the lungs, which under normal breathing fail to fill 
completely, decreasing the amount of residual air, and in turn developing 
the lung power. The close relation between the cardiac and pulmonary 
systems under exercise cannot be underestimated when one visualizes not 
only their mechanical proximity but the marked influence of the pul¬ 
monary circulation upon both the cardiac and respiratory systems. 

Effect of Exercise on Digestion. —One of the most important factors 
in the effect of exercise upon the digestive system is the action of the 
diaphragm. Forceful contraction of this muscle, increasing intra¬ 
abdominal pressure, increases the rapidity of flow in the great splanchnic 
vessels and also exerts some pressure upon the vena cava as it passes 
through it. Increased activity of the diaphragm and of the abdominal 
muscles improves the peristaltic action, also, according to some authors, 
acting as a sort of liver and gall-bladder massage. The increased peristaltic 
action places greater demand upon the intestinal secretory glands, im¬ 
proving the absorption and assimilation of the food, which in turn results 
in an improved nutrition of the body in general. 

The striking effect of exercise is seen among those who do active out¬ 
door work. It is not uncommon for such people to have a daily intake of 
from 4,000 to 5,000 calories, while those of sedentary occupations rarely 
ingest more than 2,000 to 2,500 calories per day. 

Effect of Exercise on Nervous System. —One of the most important 
effects of exercise is seen upon the brain and nervous system. This is 
particularly true of special exercises given for therapeutic purposes. Pre¬ 
cision in movement requires an alert mental effort and rapt attention to 
the work at hand. In exercises directed locally the patient is required 
to differentiate between the workings of the individual muscle groups 
supplied by various innervations, giving him an acute appreciation of 
control of the various muscle groups. This is of particular value in cases 
of partial paralyses where the improvement of the remaining muscles of 


244 


MECHANOTHERAPY 


the same group would, to some degree, compensate for the loss of an in¬ 
dividual muscle. 

Erankel has correlated a complete system of exercises which have 
accomplished much in re-training those suffering from locomotor ataxia, 
utilizing the other sense perceptions for the loss of muscle sense percep¬ 
tion. The effect of exercises on purely functional neurological conditions 
is not to be disregarded. By means of properly applied exercise, either 
a sedative or stimulating effect may be obtained. Many of the purely 
functional neurological conditions have recently been explained upon the 
basis of an endocrinasthenia, and it is possible that the effect of exercise 
in these cases is accomplished by the physiologically improved function 
of the organs of internal secretion through increased blood supply and 
nutrition. 

Effect of Exercise on Genito-urinary System. —The most important 
physiological effect of exercise on the genito-urinary system is the tem¬ 
porary relief of passive congestion when present in the kidney. The 
changes above noted in the circulatory system, the distribution of blood 
to other parts of the body, the diaphoresis occurring with exercise, all 
relieve the kidney of work which it would ordinarily be called upon to 
do. However, this is a rather transient accomplishment, and does not 
warrant the prescription of exercise for dysfunction of the kidney, save 
in carefully selected cases. The reflex depletion of the blood to the entire 
genital apparatus is of more importance, thereby lessening local 
irritability. 

Effect of Exercise on Metabolism.— No other therapeutic agent has 
so definite an effect upon metabolism as exercise. Howell has tabulated 
the mechanisms of heat production and heat dissipation as follows: 

Heat production. 

Chemical regulation. 

1. Motor nerve centers and motor fibers to the muscles. 

2. Stimulating action of food on metabolism. 

Heat loss. 

Physical regulation. 

1. Sweat centers and sweat nerves. 

2. Vasomotor centers and vasomotor nerves. 

3. Respiratory center. 

In this we see the important metabolic process of heat regulation 
definitely acted upon by exercise. Heat loss through the sweat centers, 
vasomotor centers and respiratory center, is definitely accelerated exer¬ 
cise; while, on the other hand, heat production, although of chemical 
regulation, is likewise accelerated by exercise. The acceleration of the 
metabolic processes has, coincident with it, an acceleration of the di¬ 
gestive functions, permitting more rapid assimilation. This not only 
permits a greater intake of food, but its more rapid absorption, thereby 
improving the general body economy. 


THERAPEUTIC EEEECTS OF EXERCISE 


245 


Physiology of Muscles. —Before considering this very important aspect 
of muscles, let us review briefly the histological structure of muscle, 
upon which its physiology depends. The essential unit of the muscle 
is the fiber a minute, highly specialized body cell, appearing as a 
minute thread varying from .01 mm. to .1 mm. in diameter, and from 
5 to 15 cm. in length. This is made up in turn of a sarcolemmal sheath 
within which is contained the sarcous substance or muscle plasma. The 
sarcolemma is a structureless, elastic membrane and it alone comes in 
contact with the connective tissue by which the muscle fibers are attached 
one to another. The muscle plasma is made up of long threadlike fibrils 
which, being of alternate light and dark bands, give a characteristic cross 
striation to the muscle, and which are the essential contractile portion 
of the muscle. The viscous material between the fibrils, known as the 
sarcoplasm, is supposedly the nutritive element in the muscle fiber. 
Muscle fibers are banded together by delicate connective tissue which 
groups them into primary bundles, this connective tissue portion being 
known as the endomysium. The sheath surrounding the primary bundles 
is the perimysium. These primary bundles are again grouped into 
secondary bundles and enveloped in a sheath known as the epimysium, 
each secondary bundle being known as a separate muscle fasciculus. 

The physiological properties of striated muscle are: 

1. Contractility .—By this we mean its ability to shorten itself in 
response to a stimulus by which it is able to perform its work. The 
normal stimulus is usually the nerve impulse, voluntary in the striated 
muscles and acting reflexly in the unstriated muscles. While this prop¬ 
erty of contractility is present in all muscular tissue, it is not confined 
to muscular tissue, being also a property of the ciliated epithelial cells 
of the mammalian body. Through this contractile power muscles shorten 
themselves in varying degrees, this variation being from 10 per cent 
to 50 per cent of their normal lengths during physiological exercise. 

2. Extensibility .—By extensibility we indicate the power of muscle 
to permit of lengthening without tearing. Most muscles are stretched 
between their points of origin and insertion. We know that if a tendon 
is cut, even with the muscle relaxed, the fleshy part, of the muscle draws 
the tendon toward its origin. This slight stretching under which the 
muscles are normally maintained assists very much in the smooth working 
of the motor apparatus. This power of extensibility, when studied in 
comparison with the extensibility of dead elastic bodies, is found to differ 
markedly from them. While the extensibility of an elastic band is pro¬ 
portionate to equal increments of weight, the extensibility of muscle 
shows a proportionate decrease with each equal increment of weight. 
It has been found that the decrease in the power of extensibility to 
increments of weight holds true up to the point where a muscle reaches 


246 


MECHANOTHERAPY 


its normal physiological limit of extension. If equal weights are added 
after this point, the muscle follows the law of dead elastic bodies and 
extends in equal proportions to each added increment of weight. Ex¬ 
tensibility remains a property of muscle even after rigor mortis. 

3. Elasticity .—When a muscle has been extended within its physio¬ 
logical range of extensibility and the extending force is removed, it 
regains its normal state through its power of elasticity. This property 
is found only in living muscle, and although it is not as great as the 
elasticity found in some dead elastic bodies, its elastic power is none 
the less perfect. The slightly stretched condition of muscle between 
its origin and insertion probably tends to maintain the tone of the 
muscle, thereby making more smooth the elastic recoil. 

4. Irritability .—Muscle irritability is the functional activity of a 
muscle in response to a stimulus. The normal nerve stimulus was first 
eliminated by Claude Bernard, who, by injecting curare, paralyzed 
the motor nerve endings. Direct stimulation of the curarized muscle, 
either electrically or mechanically, initiates functional activity within 
the muscle, demonstrating an independent muscle irritability. 

It is through these four properties that muscles perform their normal 
work and through the improvement of these properties that exercise 
restores function to the muscle. 


CLASSIFICATION OF GYMNASTIC MOVEMENTS 

Ling classified all movements as follows : 

1. Passive movements, or those wherein no active innervation is performed 
by the individual, the motor power being supplied by another person or by suit¬ 
able “live” apparatus. 

2. Active movements, or those wherein the individual innervates his own 
muscles and performs work through the movements of his muscles. Active 
movements are again subdivided into: 

a. Free movements, those performed by the individual without external help. 

b. Controlled movements, by which is meant those exercises limited or sup¬ 
ported by various apparatus. 

c. Resistance movements, during which the active movements performed by 
the patient are resisted by the gymnast or by apparatus. 

Resistance movements are said to be either concentric or eccentric. 
Concentric movements are those in which the muscle, while working 
against resistance, shortens its total length; while eccentric movements 
are those during which the muscle, while working, is gradually length¬ 
ened by the external force applied. This may be illustrated by resistant 
movement, when a patient flexes his knee with the resistance of the 
masseur’s hand or machine directed against the back of the patient’s 


CLASSIFICATION OF GYMNASTIC MOVEMENTS 247 

leg, the hamstring muscles are shortened and are active concentrically. 
If, however, the same patient with knee flexed attempts to hold the 
knee in this position and is overcome by the force utilized by the masseur 
or machine, the flexor muscles are still working, but actually being 
lengthened while working and hence are said to work eccentrically. 

Active motion is also divided into- three phases of muscle action: 

1. Positive phase in which a muscle contracts. 

2. Static phase during which the muscle is maintained in a state 
of complete or incomplete contraction. 

3. Negative phase during which muscle ends are gradually being 
separated. 

To illustrate—during dorsi flexion of the wrist, the extensor carpi 
ulnaris and radialis perform a positive action. If the wrist is now 
maintained in dorsi flexion without further movement, a static action 
of these muscles is seen. As the wrist is then lowered, complete relaxa¬ 
tion of these muscles does not occur immediately, but they are gradually 
lengthened as the wrist is brought down. This is the negative activity 
of a muscle. 

One of the most important factors in proper application of exercise 
is the localization of the treatment to the joints and muscles to he exer¬ 
cised. If we take, for example, a foot condition wherein adduction 
exercises are indicated, and during exercise permit the patient to plantar 
flex the foot alone, instead of adducting, we are defeating the purpose 
for which the exercise was prescribed. 

According to Schwann’s law of the physiological action of muscle, 
we know that the strength of a muscle is in direct proportion to its state 
of contraction. This is of importance in graduating the dosage of re¬ 
sistance in giving resistive movements, for, at the beginning of contraction 
and at the end, the strength of the muscle is lessened so that the resistance 
should he strongest in the middle third of the movement. Again, in the 
treatment of a regenerating musculospiral nerve, when the extensors 
of the wrist and fingers are beginning to show return of function, if we 
instruct the patient to move the wrist in extension as much as possible 
instead of ordering a few brief, well-directed extensor movements to his 
wrist, he will, in his efforts to extend the wrist, activate his flexor groups 
as soon as the extensor muscles are fatigued, thereby actually causing 
the exercise to be detrimental to his recovery. The progression of exer¬ 
cise should he gradual and may he accomplished by increasing speed, 
duration or resistance applied in the exercise. 

General Exercises.—We know it is general bodily activity that main¬ 
tains the harmonious coordination of the various systems of the body. 
It is reasonable, therefore, to suppose that in the application of exer¬ 
cises in a therapeutic way, active free exercise offers most improvement 


248 


MECHANOTHERAPY 


in bodily function, and it is only in those cases wherein active free 
exercises cannot be accomplished that the passive form of exercise or the 
use of mechanical means are indicated. Many so-called systems of active 
exercises have been developed but none have superseded the original 
Swedish system originated by Ling and his followers. This school had, 
as its basis, five fundamental positions, namely, standing, sitting, kneel¬ 
ing, lying and hanging. Erom these positions the derived positions 
were taken. For instance, from the standing position, arm, leg and 
trunk exercises are given. Likewise, from the sitting position the arm, 
leg and trunk exercises may be given, and so on, utilizing the funda¬ 
mental positions as a starting point and building the individual exercises 
or derived positions from these fundamental positions. It is readily seen 
that countless numbers of combinations of exercises may be worked out 



Fig. 1.—Fundamental Positions from which Exercises May Be Derived. In out¬ 
lining a table of exercises for a given condition, the standing or lying position is 
first utilized, from which derived movements are made, dependent upon the fatig¬ 
ability of the patient. As improvement is gained, the period of exercise is length¬ 
ened, gradually manual resistance may be offered and still later other fundamental 
positions utilized until eventually the patient is able to tolerate all of the various 
fundamental positions with their derived exercises. In the local treatment of a 
part by exercise, resistance movements are of greatest value in improving local 
function. 

from these fundamental positions. The accompanying sketches illustrate 
the five fundamental and a few of the derived positions from the various 
fundamental positions (Eigs. 1 and 2). 

Passive Movements. —-Passive movements have, heretofore, been cred¬ 
ited with far greater range of applicability than they are to-day. Those 
who are constantly using exercises in a therapeutic way appreciate that, 
aside from the relatively limited number of cases wherein actual joint 
stretching is required, or where the slight local circulatory improvement 
resulting from passive motion is indicated, passive exercises have little 
therapeutic value. It is readily seen that where a muscle fails to receive 
its own nerve supply its irritability and contractility are not stimulated 
to activity. It is true that the elasticity and extensibility of the muscle 
are called into play, but the injury sustained by the contractile fibers 
would hardly be compensated for by the improvement gained in the 
elastic or extensible structures. However, passive movements have an 
important role to play in the treatment of chronic joint affections, where 


CLASSIFICATION OF GYMNASTIC MOVEMENTS 249 

contractions in capsules, ligaments or synovial membranes may be defi¬ 
nitely improved by gradual, slow, even movements given over long 
periods of time. Passive exercises are rarely indicated in the lower 



Fig. 2.—A Few Derived Movements from the Fundamental Positions. 

extremity, for what cannot be accomplished by ordinary walking will 
surely not be accomplished through the application of passively applied 
movement. 

Mechanical Aids. —Many kinds of apparatus have been devised to 
exercise a part or the whole of the body. Among these, the best known 


















250 


MECHANOTHERAPY 


are the Zander, based on the principle of the lever with movable weight; 
the Krunkenberg pendulum apparatus; and the Herz modification of 
the Zander apparatus. If we disregard the passive movement machines, 
whose sphere of action is very limited, we find that the importance of 
the machines lies in the resistance to efforts against a muscle, and the 
localization of exercise to definite muscle groups. This resistance may 
he afforded by the weight and lever Zander, by friction against a brake 
in the turning of a wheel, or by stretching or compressing springs. The 
principle of raising a weight by means of a lever has more recently 
been modified to raising weights by rope and pulley. 

Scholz, in his Manual of Mechanotherapy, states that “apparatus for 
medical gymnastic exercises should meet with these requirements: 

“1. It must be constructed in such a way that the patient in the 
apparatus is in the correct, original position, that is, the apparatus must 
prevent any indirect, secondary contractures of muscles. This is obtained 
by arrangement for support and fixation. 

“2. The apparatus must allow the intended position properly to be 
done from an anatomical, as well as from a medical gymnastic point of 
view. 

“3. It must allow exact dosage and control of quantity of exercise. 

“4. Apparatus for resistive movements must allow exact dosage and 
regulation of the exercise which is to be given.” 

Following Ling’s development of a rational system of free exercise, 
Zander constructed apparatus by which exercise might be given without 
the assistance of a trained gymnast. He constructed in all some thirty- 
six machines for active movements, including those for the upper and 
lower extremity and trunk. He then devised motor-driven apparatus for 
balance movement, passive movement, vibration, percussion and knead¬ 
ing and friction. Along with these, machines for the correction of 
scolioses and various measuring apparatus completed his contribution 
to mechanotherapy. The machines for active exercise were constructed 
on the principle of the weighted lever, by which certain muscle groups 
were activated by the movement of the lever. The degree of resistance 
was graduated by moving the weight upon the lever. Motor-driven pas¬ 
sive exercise machines were constructed upon the same principle, and 
were of definite value in that the smoothness, continuity and uniformity 
of the movement was superior to that applied by a gymnast. 

The advantages of the Zander apparatus lie in the graduation of the 
force and resistance, the human factor of the gymnast being eliminated. 
However, the proper application of the machines requires the attendance 
of one trained in therapeutics of exercises to gage the amount of re¬ 
sistance required and to sense the expressions of fatigue when the 


CLASSIFICATION OF GYMNASTIC MOVEMENTS 251 


exercises are applied. In addition to this, the machines are expensive, 
rather cumbersome to operate, requiring motor force, much space and 
shafting, and the constant care of a mechanic to keep them in working 
order. Where these are not ob¬ 
jections, the Zander apparatus 
may be used with decided bene¬ 
fit. 

Under the stimulus of the 
war, E. A. Bott, of Toronto, and 
B. Tait McKenzie, of Philadel¬ 
phia, developed simpler appa¬ 
ratus based on the raising of 
weights by rope and pulley prin¬ 
ciple, and of extreme simplicity 
in construction. The general 
principle of raising weights, as 
in the Zander apparatus, is 
maintained and the objection¬ 
able factors, namely, the cum¬ 
bersomeness, difficulty of opera¬ 
tion, space and technical knowl¬ 
edge required in the Zander 
apparatus are eliminated. These 
machines are constructed so as 
to exercise one movement in a 
joint, and are all active motion 
machines, save those for circum¬ 
duction in the wrist and ankle. 

These are so-called active-pas¬ 
sive machines, that is, the move¬ 
ment is started, as in the Krunk- 
enberg pendulum apparatus, by 
revolving a wheel to start the 
exercise, and the wheel is kept 
moving by the activity of the 
patient’s own muscles. Many of 
the machines are fitted with 
scales, particularly those for the 

hands and feet, whereby a patient may actually see the graded improve¬ 
ment, and this acts as a stimulus to further effort. The triplicate-pul¬ 
ley weight machine, shown in Figure 3, shows the simplicity whereby 
resistance may be arranged upward, downward or from the side. 
Dosage or resistance is graduated by the addition or elimination of 
weight. 



Fig. 3.—Triplicate-pulley Weight Machine 
By Which Resistance May Be Offered 
Upward, Downward or in the Horizontal 
Direction. 





















252 


MECHANOTHERAPY 


McKenzie gives the following instructions for the use of the various 
types of apparatus: 


Upper Extremity 

1. Finger Board. —(&) For stretching contractions of the fingers, in 
flexion, and (6) for stretching abduction at the metacarpophalangeal 
joints. 

Extension of Single Fingers. —(a) The fingers are placed on the board 
in moderate flexion, and the finger under treatment goes up the stair, step 



Fig. 4.—Finger Pulleys. 


by step. Note the last step at which the finger under treatment can he 
raised from the step without assistance. Depress the hand to stretch 
still farther. 

( b ) Place the index finger against the peg at 1, and spread the second 
finger out, noting the farthest point at which it can touch the peg. Repeat 
with the second, third, and fourth fingers. Repeat each movement not 
more than five times. 

2. Finger Pulleys (Fig. 4).—For flexion and extension of the fingers, 
strap the wrist and arm at the elbow, insert the fingers into the glove 
stools and add weight until it can barely be lifted by the voluntary power 
of each finger. The weights are increased as improvement goes on, and 
the movements repeated up to the point of exhaustion. 

Exercise 1 .—High attachment. Flex metacarpophalangeal joints, 
keeping interphalangeal rigidly extended. 




CLASSIFICATION OF GYMNASTIC MOVEMENTS 253 

Exercise 2. Horizontal attachment. Flex interphalangeal joints, 
keeping metacarpophlangeal joints extended. 

Exercise S. Low attachment. Extend metacarpophalangeal joints, 
keeping metacarpophalangeal joints extended. 

Exercise Jf. Low attachment. Extend metacarpophalangeal and flex 
interphalangeal joints. 

The operator seated opposite the patient should count the repetitions 
and encourage his efforts. Each exercise to be continued till movement 
shows flagging, and then stopped. The most convenient weights are shot 
bags, loaded to two ounces each and attached by hooks. They can easily 
be made and repaired by the masseur. 



Fig. 5.—Finger Treadmill. 


3. Thumb Adduction and Abduction. —Hand in pronation. Attach 
the stool on the radial side to the thumb for adduction. 

Exercise 1 .—Draw the thumb across the hand. Repeat the movement 
to the point of exhaustion. 

Exercise 2 .—Attach the stool on the ulnar side of the thumb; draw 
thumb out in abduction. Repeat to exhaustion. 

4. Finger Treadmill (Fig. 5).—For voluntary flexion of fingers. 
Strap the wrist and turn the wheel by flexing the fingers in turn till ex¬ 
haustion of each finger. The amount of work done by a single finger can 
be calculated by using that finger only, and noting the weight and distance 
it is raised. 

5. Circumduction of Wrist for Stretching (Fig. 6).—Strap the wrist 
and forearm, grasp the handle, and turn the wheel about twenty revo- 




254 


MECHANOTHERAPY 




Fig. 6.—Circumduction at the Wrist. Apparatus may be used actively and passively. 

lutions each way. Move out the attachment to the farthest possible point 
compatible with the movement. The operator may assist at the most diffi¬ 
cult part, of the turn by turning the crank. 


Fig. 7.—Abduction and Adduction of Wrist. Note scale showing range of motion 
and small handle to brake machine to increase resistance. 

6. Adduction and Abduction of Wrist (Fig. 7).—Place the fingers 
under the straps on the hand board, strap down the wrist and forearm, 






CLASSIFICATION OF GYMNASTIC MOVEMENTS 255 


adduct and abduct the hand, noting the range of movement on the pro¬ 
tractor. The weights will vary for these two movements, which should 
be done separately. 

7. Flexion and Extension of Wrist. — (a) Grasp the roller overhand 
and wind up the weight, exerting the full range of movement without 
releasing the grasp. The scale will measure the range of the joint, and 
the weight and distance multiplied gives the total work done in foot 
pounds. ( b ) Reverse the grasp and repeat for flexion. 

8. Pronation and Supination (Fig. 8).—Patient stands facing ma¬ 
chine and grasps the handle with the left hand, his left elbow joint flexed, 



Fig. 8.—Pronatton and Supination of Wrist. 


his right forearm across his back, and his hand grasping his left arm above 
the elbow to prevent sideways movement. Set weight and ratchet for 
supination and turn, counting the clicks for each movement and noting 
the weight and the distance raised. The measurement of each movement 
will appear on the protractor. Reverse the ratchet and repeat for 
pronation. 

9. Flexion and Extension at Elbow. — (a) The patient faces the 
triplicate machine, grasping the floor handle, the arm and cord in line. 
Flex and relax the forearm. ( b ) Patient faces away from the machine, 
grasping the shoulder handle, the arm full flexed, the upper arm in line 
with the cord. Extend and relax the forearm. In both these exercises 
the position of the upper arm must remain unchanged. If this is not 
done, the direction of the pull is changed. 




256 


MECHANOTHERAPY 



10. Shoulder Rotation. —Grasp the floor handle, the elbow on a 
bracket, shoulder high, the forearm flexed to a right angle. Pull up with 
the hand, throughout whole range of shoulder movement without chang¬ 
ing the height of the elbow or its angle of flexion. 

11. Flexion and Extension of Shoulder Joint. — {a) The patient 
stands with his back to the floor handle, the arm down and straight. Arm 
forward, raise and lower. (5) Face to the floor handle, draw the arm 
back, and lower to position. 

12. Adduction and Abduction of the Shoulder. —The patient stands 
with the side to the triplicate machine, shoulder attachment, arm and cord 
in line, (a) Bring the arm forward across the chest. ( b ) Patient stands 


Fig. 9.—Circumduction of Ankle. 

as in Exercise 1, but using the floor attachment. Bring the straight arm 
upward and lower to position, (c) Patient stands with his side to the 
machine, overhead attachment, arm in line with the cord. Bring the arm 
downward and forward, then downward and backward, alternately. ( d ) 
Patient stands with the side from the machine, the arm across chest, grasp¬ 
ing the shoulder attachment. Extend the forearm and arm, keeping them 
at the shoulder level. 

13. Passive Abduction of Shoulder. —Patient standing with the side 
to the creeping board, and the forearm rigidly extended. Climb up the 
board by the fingers with a straight arm, and note: (a) the highest point 
at which the fingers can be lifted from the board by the patient; ( b ) the 
level to which the patient can bring up his arm, without bending his 
elbow. 








CLASSIFICATION OF GYMNASTIC MOVEMENTS 257 


General movements that are of value in treating the muscles of the 
upper extremity are rolling up a ball of paper, throwing and catching balls 
of all sizes and weights, quoits, bowling, ping-pong, crokinole, billiards, 
weaving, knitting, rope splicing, making knots, the use of tools such as 
scissors, boring, hammering, modeling, painting, bookbinding, saddlery, 
and shoemaking. 


Lower Extremity 

1. Circumduction of the Ankle (Fig. 9).—The patient sits with his 
foot strapped in place. The range of movement is regulated by a thumb 
screw on the crank. The handle is 
turned by the patient or operator, 
for this stretching movement, 
which should precede the voluntary 
active movements of the ankle. 

2. Inversion and Eversion of 
Foot (Fig. 10).— (a) The patient 
walks on the inversion ridge, a 
definite distance, with hand-rail 
support; (b) ditto for eversion. 

3. Dorsiflexion of Ankle.— 

The patient sits or stands with his 
foot strapped to the footpieee. 

Flex the ankle, raising the weight. 

The extent of the movement may 
be estimated by the number of 
clicks, the exact measurement 
noted on the protractor, and the 
total work done is easily calculated. 

4. Rotation of the Knee.— (a) 

Patient is seated with the foot 
strapped to the footpieee, and the 
leg against the brace. He adduces f IGi io.—Inversion and Eversion Boards. 
or abducts the foot, rotating the 

knee, the extent of each movement being marked on the protractor, (b) 
The patient stands with the knee locked in extension and adducts or abducts 
the foot. This movement measures hip rotation, if care is taken to keep 
the pelvis fixed. In either position, the movement of the flexed ankle is 
slight. 

5. Knee Flexion and Extension (Fig. 3). — Triplicate machine. 

Exercise 1. Face to the machine, strap the foot to the floor attach¬ 
ment. Movement : Flex the knee against resistance. 







258 MECHANOTHERAPY 

Exercise 2. Face from the machine, strap the foot to the floor attach¬ 
ment, the flexed leg and cord in the same line. Movement: Extend the 
knee against resistance. 


Fig. 11.—'Stationary Bicycle. Thigh and knee extension, plantar flexion of foot. 
6. Hip Adduction and Abduction. —Triplicate machine. 


Fig. 12.—Grip Machine for Improving Flexion of the Fingers and Flexion and 

Extension of the Wrist. 






CLASSIFICATION' OF GYMNASTIC MOVEMENTS 259 

Exercise 1. Side ^to the machine, the foot strapped to the floor 
attachment. Movement: Adduct the thigh, keeping the knee straight. 

Exercise 2 . Side from the machine, foot strapped to the floor attach¬ 
ment. Movement: Abduct the thigh, keeping the knee straight. 

7. Hip flexion and extension. 

Exercise 1 . Face to the 

machine, foot strapped to the 
floor attachment. Movement: 

Extend the thigh with the leg 
stretched. 

Exercise 2. Face from 
the machine, foot strapped to 
the floor attachment. Move¬ 
ment : Flex the thigh, keeping 
the knee straight. 

8. Thigh flexion, knee 
flexion, foot dorsiflexion.— 

Patient steps through the 
rungs of a horizontal ladder 
with parallel bar arm rests. 

The ladder is made adjust¬ 
able for height at one end, 
and raised, to increase the 
movement required to raise 
the foot over each rung. This 
is especially useful for leg 
amputation cases. 

9. Thigh extension, knee 
extension, foot plantar flex¬ 
ion. The bicycle trainer with 
an increasing load of distance 
or friction (Fig. (11). 

Mensuration. —B efore 
starting exercise it is well to 
know the range of motion present at a joint so that comparison may he 
made after a short period of treatment to see whether or not improvement 
in range of motion is taking place. Under too active exercise or in those 
cases where the muscles under active-passive exercise are strained, further 
limitation of motion may be detected. 

Several simple devices have been devised consisting of jointed arms 
with a protractor scale, one arm being fixed at zero on the scale and the 
other movable about the protractor, indicating in degrees as it moves the 
arc through which it passes. This simple form is most useful in measur¬ 
ing the range of motion in the joints of the extremities. In some of 



i. 13 .—One Type of Protractor Scale to Meas¬ 
ure Range of Motion. One arm remains sta¬ 
tionary at zero, the other arm free. A double 
protractor scale facilitates the taking of meas¬ 
urements on the two sides of the body. 





260 


MECHANOTHERAPY 



Fig. 14.—Rosen Type of Apparatus for Indicating Range of Motion at the 
Metacarpal and Phalangeal Joints. 


these instruments the pro¬ 
tractor scale registers from 0 
to 180, while in others it reg¬ 
isters from 0 to 360. The 
accompanying photograph il¬ 
lustrates one type of pro¬ 
tractor, with double scale fa¬ 
cilitating its use on the oppo¬ 
site sides of the body (Eig. 
13). 

It has been found that the 
measuring of finger motions 
with the protractor scale of¬ 
fers some difficulties, so that 
a. simpler form of measuring 
apparatus was devised to plot 
out the actual range of mo¬ 
tion in the metacarpophalan¬ 
geal joints. This consists of 
a small wooden bar which fits 
over the dorsum of the meta- 
Fig. 15. —Dynamometer for Measuring Grip of car P a ^ bones, jointed to a thin 
Hand. sheet of celluloid or tin, 







CLASSIFICATION OF GYMNASTIC MOVEMENTS 261 


which fits between the fingers. The joints are indicated with a pencil by 
dots on the celluloid, in both full flexion and full extension. The hand 
is then removed from the instrument, the dots connected by straight lines 
and this transposed to permanent record. This is illustrated by the Rosen 
apparatus in Figure 14. 

To appreciate the limitation in range of motion in the joint, it is well 
to have at hand the normal mean range through which a joint moves. 
The following table shows the normal range usually present in joints of 
the extremity: 

Wrist joint 

Flexion to 100 degrees. Extension to 240 degrees. Range—140 degrees. 

Abduction—zero to 35 degrees. Range—35 degrees. 

Adduction—zero to 50 degrees. Range—50 degrees. 

Elbow Joint 

Flexion to 45 degrees. Extension to 180 degrees. Range—135 degrees. 

Pronation—zero to 90 degrees. Range—90 degrees. 

Supination—zero to 90 degrees. Range—90 degrees. 

Shoulder Joint 

Abduction—zero to 160 degrees. Range—160 degrees. 

(Note.—From zero to 80 degrees is the range in the shoulder joint itself, 
while, from 80 to 160 degrees, movement is made by elevation and rotation 
of the scapula.) 

Flexion—zero to 180 degrees. Range—180 degrees. 

Extension—zero to 45 degrees. Range—45 degrees. 

Internal rotation—zero to 80 degrees. Range—90 degrees. 

External rotation—zero to 45 degrees. Range—45 degrees. 

Ankle Joint 

Dorsiflexion—90 degrees to 135 degrees. Range—45 degrees. 

Plantar flexion—90 degrees to 70 degrees. Range—20 degrees. 

(Note.—Inversion and eversion of the foot cannot be measured with these 
simple instruments.) 

Knee Joint 

Flexion to 45 degrees. Extension to 180 degrees. Range—135 degrees. 

Hip Joint 

Abduction—zero to 45 degrees. Range—45 degrees. 

Adduction—zero to 45 degrees. Range—45 degrees. 

Flexion to 60 degrees. Extension to 180 degrees. Range—120 degrees. 

Hyperextension from 180 degrees. Extension to 135 degrees. Range—45 
degrees. 

External rotation—zero to 60 degrees. Range—60 degrees. 

Internal rotation—zero to 30 degrees. Range 30 degrees. 

Indications and Contra-indications 

Indications.—Generalized exercises are indicated in those of sedentary 
occupation, wherein the general metabolism has fallen below its normal 
threshold, and is evidencing itself by disturbances in one or more of the 
systems comprising the body. In purely systemic diseases, such as. in 
compensated chronic endocarditis or enteroptosis, a rationally applied 


262 ME CH ANOTHER APY 

general system of graduated exercises will accomplish more than any 
other form of therapeusis. Again, in the functional neurological condi¬ 
tions so often grouped under the vague term of “neurasthenia,” general¬ 
ized exercise, by increasing the general metabolism and possibly by stimu¬ 
lating the organs of internal secretion, is frequently markedly beneficial. 

The local indications for exercise consist in the limitation of function 
of a part, whether it is a joint, tendon or organ. In the last, as may be 
represented by a retracted lung in a healing empyema, the exercise of that 
portion of the motor apparatus, namely the chest, secondarily acts locally 
upon the organ within. Local circulatory derangements, atrophies and 
contractures can frequently be prevented as well as improved, when pre¬ 
senting, by the early institution of exercise properly applied. 

Contra-indications. —The contra-indications to exercise include all 
those conditions in which the raising of the basal metabolism is detri¬ 
mental. Inflammations of all kinds, advanced depleting disease, and new 
growths are definite contra-indications to exercise. Local, healing, in¬ 
flammatory disorders, by increasing the local metabolic changes, hasten, 
rather than retard improvement. However, although this is true, care 
must be exercised in the selection of the time when exercise will not pro¬ 
mote an extension of the inflammatory process. A short list of suitable 
cases follows, arranged as to the indications requiring local or general 
exercises. 

1. Requiring General Exercise. 

Constipation. 

Enteroptosis. 

Gastric or intestinal neurosis. 

Chronic passive congestion. 

Marked compensated cardiac valvular disease. 

Compensated myocarditis. 

Arterial hypertension. 

Arterial hypotension. 

Atelectasis. 

Postoperative empyemas. 

Chronic pleuritic adhesions. 

Neurasthenia. 

Hysteria. 

2. Requiring Local Exercise. 

Torticollis, congenital and spasmodic. 

Fractures, following reduction. 

Dislocations, following reduction. 

Amputations, postoperative. 

Ankylosis, fibrous. 

Arthritis, chronic. 

Contractures, cicatricial, muscular or tendinous. 


REFERENCES 


263 


Reduced epiphyseal separations. 

Foot affections. 

Weak feet. 

Congenital or acquired club-foot, following correction. 

Metatarsalgia, 

Sprains. 

Scolioses. 

Regenerating peripheral nerve injuries. 

Paraplegias. 

Hemiplegias. 

Ataxias. 

REFERENCES 

Arvedson, J. Medical Gymnastics and Massage, J. & A. Churchill, 
London, 1921. 

Boehm, Mas. Massage, Its Principles and Technic, W. B. Saunders 
Company, Philadelphia and London, 1913. 

Bucholz. Manual of Therapeutic Massage and Exercise, Lea, Philadel¬ 
phia, 1917. 

Frenkel, H. S. Treatment of Tabetic Ataxia, Rehman, Ltd., London, 
1914. 

Graham, D. Massage, 4th ed., Lippincott, New York, 1913. 

Howell. Physiology, W. B. Saunders Company, Philadelphia, 1918. 

Jones, Sir Robert. Orthopedic Surgery of Injuries, Oxford University 
Press, London, 1921. 

-Injuries to Joints, Henry Froude and Hodder & Stoughton, Lon¬ 
don, 1922. 

Kleen, Emil A. Massage and Medical Gymnastics, 2d ed., Wood & Com¬ 
pany, New York. 

McKenzie, R. Tait. Reclaiming the Maimed, Macmillan, New York, 
1918. 

Nissen. Practical Massage and Corrective Exercises, 4th ed., F. A. Davis. 



CHAPTER VII 


OCCUPATIONAL THERAPY 
William V. Healey 

Introduction. —For many years medical men have realized that pro¬ 
longed illness or disability, particularly in patients requiring prolonged 
hospitalization, was frequently accompanied by a mentally depressed or 
lethargic state, which was rarely overcome until the patient was able to 
return to his former occupation, or at least some occupation. It was 
not an uncommon sight, ten years ago, in entering a hospital ward, to see 
twenty or more patients, in all stages of illness, either lying quietly in 
bed gazing at the usual blank hospital walls, or sitting up aimlessly, oc¬ 
casionally reading, but for the most part doing nothing. Nurses, at times 
noting certain patients more depressed than others, would give them 
heaps of cut gauze to fold, and this simple measure frequently trans¬ 
formed a much worried and depressed individual, lying disgruntled in 
bed, into a more or less cheerful one, sitting up in bed and, while work¬ 
ing, talking to his neighbor. 

A few thoughtful persons prior to this time, with keen insight into 
the psychology of the sick, advocated keeping hospital patients busy. 
They appreciated, of course, that those seriously ill or in a critical condi¬ 
tion could do no work, but the large percentage of hospital patients 
during their stay in the hospital frequently spent two-thirds of their 
time in a more or less convalescent condition, which time they could im¬ 
prove by suitable work, thereby not only improving themselves physically, 
but psychologically preparing themselves for their return to their former 
or other occupations. For many years occupations of various sorts have 
been sought for the blind and for those suffering from mental disorders, 
and the beneficial effects in these types of cases have been too well rec¬ 
ognized to require more than passing comment. But it has been the work 
accomplished by these types of cases that has done so much toward the 
establishment of the idea that occupation is one of the best means we 
have for aiding in the recovery of the sick or maimed. 

Manual work has been well recognized for many years as a therapeutic 
agent in the treatment of mental diseases. In the medical literature of 
264 


INTRODUCTION 


265 


tlie eighteenth century, references are made indicating that it was even 
then appreciated that occupation was of definite value in neuropsychiatric 
cases. Benjamin Rush, in 1801, in speaking of methods of treatment 
for nervous disorders, advocated teaching the roots of the mechanical arts. 
In 1822, Dr. Wyman, Superintendent of McLean Hospital, stated that 
amusements provided in the establishments for lunatics, such as chess, 
backgammon, ninepins, swinging, sawing wood, gardening, reading, writ¬ 
ing, music, etc., afforded exercises both of body and mind and had a 
powerful effect in tranquilizing, breaking up long associations of days, 
and inducing correct habits of thinking as well as acting. 1 The annual 
reports of superintendents of many insane asylums during the last hun¬ 
dred years point out the same trend of thought, and are more or less 
unanimous in their approval of work as a remedial agent in improving 
the physical well-being, and composing the restless and excited conditions 
of the patients. 

It is interesting to note that the type of work selected during the early 
years, in using occupation as a curative agent, consisted largely in agri¬ 
cultural labor, carpentry, and drawing and painting. Later, the diver- 
sional occupations were made use of, hut, as late as 1898, Dr. Hoyt, of the 
Iowa State Hospital, stated that “no greater diversity of employment, 
no more methodical application of this form of treatment could be re¬ 
ported than was done fifty years ago.” However, during the past fifteen 
or twenty years, definite advancement has been made, not only in the 
selection of suitable work for the insane and blind, hut also in the prin¬ 
ciple of applying suitable occupation for those of sound mind, but 
physically handicapped. In 1910, Invalid Occupation, by Susan B. Tracy, 
appeared, showing the value of occupation for the sick, with lessons in¬ 
creasing the resourcefulness of the nurses in keeping a patient occupied 
during illness. In 1914, the Massachusetts General Hospital established a 
medical workshop as a hospital department, for the use of chronic out¬ 
patients. The shop was equipped for the manufacture of cement flower¬ 
pots, seats, sundials, garden accessories, and during its first year made 
itself self-supporting. 

At Sharon, Connecticut, a convalescent home for cardiac cases was 
started where cement work, similar to that done in Massachusetts General 
Hospital, was made, the work being graded so that moderate and con¬ 
trolled exercises for the patient could he given, and at the same time 
profitable occupation afforded. In Massachusetts, the conversion of an 
old barn into the now well-known Devereaux Mansion, where occupation 
was the chief remedial agent, proved to many that, througn the agency of 
work, much could be done. 

During the last ten years, in many hospitals for chronic conditions 
such as tuberculosis, orthopedic lesions and cardiac disease, and in innum- 


1 Quoting from Dunston. 




266 


OCCUPATIONAL THERAPY 


erable private and semiprivate sanitariums, occupational therapy, through 
awakening the will and affording encouragement, has aided greatly in 
shortening the time of convalescence and the maintenance of the spirit of 
accomplishment. 

The stimulus of the War brought out the usefulness of this remedial 
agent very forcibly, when those previously active in private life were sud¬ 
denly brought into hospital environment so maimed that, in many cases, 
prolonged hospital convalescence confronted them. I do not doubt that, 
had no definite plan of occupation been outlined for them, they would 
have evolved a means of their own to keep themselves occupied. Pro¬ 
longed hospitalization without some sort of occupation is demoralizing 
The ennui seen in everyday life among those with insufficient or uninter¬ 
esting occupation is magnified in those of unsound body who cannot seek 
the diversions available for those sound in body. The establishment of 
occupational work throughout the army hospitals did much for the mainte¬ 
nance of the morale of the patients. 

At the Walter Reed Hospital, where curative workshops were estab¬ 
lished under the direction of Major Bird T. Baldwin, the effort to utilize 
occupation as a definite means in the restoration of disabled function 
was successfully accomplished. The movements required in special types 
of work were carefully studied and patients lacking function in one or 
more joints were put to work at occupations requiring these very move¬ 
ments. For example, in limitation of pronation and supination in the 
forearm, no better form of exercise could be given than the use of the 
screw driver in doing electrical work, which at the same time affords 
interesting and instructive occupation for the patient. 

In New York City, the Red Cross Institute for Crippled and Dis¬ 
abled Men, founded through the generosity of Mr. Jeremiah Milbank, 
opened up a new sphere of action, and has developed into a model in¬ 
stitution for the rehabilitation of the crippled and disabled. This In¬ 
stitute aims to train vocationally the patient around his handicap, so that 
in spite of his physical infirmities he may become partially, if not wholly, 
self-supporting. The Institute affords a school wherein those receiving 
out-patient hospital treatment may be trained during their period of 
disability for one or more hours during the day, so that, by the time 
they have reached the maximum physical improvement, they will be ready 
to take up suitable gainful occupations. 

Recently the Federal Government, appreciating the dire need of such 
necessary reeducation for the crippled or disabled, has appropriated a 
fund whereby the individual States, upon appropriation of a sum of money, 
will receive a like sum from the Federal Government for the vocational 
rehabilitation of those disabled through accident or disease. In each state 
there has been appointed a State Commissioner for Vocational Rehabilita¬ 
tion, whose duty it is to spend these appropriations in the vocational 


INTRODUCTION 


267 


rehabilitation of those applying for such assistance. This law was passed 
by Congress in June, 1920, and is known as the “Industrial Rehabilita¬ 
tion Bill.” Up to the present time, thirty-four states in the Union have 
accepted the offer of Congress, and have appropriated varying sums for 
the rehabilitation of those crippled by accident or disease, making it 
possible for any individual to receive the required training to fit him for 
work that he can do. In Hew York State, the appropriation of $75,000, 
with a like sum received from the Federal Government, provides the means 
with which physically handicapped persons may receive vocational train¬ 
ing to fit them to return to some occupation—the only limitations being 
in those cases of aged or helpless individuals, those confined in penal in¬ 
stitutions, epileptics, feeble-minded and those under the age of fourteen. 
The rehabilitation work is carried on under a Commission consisting of 
a Commissioner of Education, a member of the State Industrial Commis¬ 
sion and the State Commissioner of Health. 

To-day one hears many terms used in conjunction with the care of 
the sick and maimed, other than medical. Occupational therapy, ergo 
therapy, functional reeducational, rehabilitation therapy, vocational train¬ 
ing and rehabilitation, curative occupation and countless others, all of 
which border upon and merge into each other, yet differ from each other 
in the stage of illness at which they are utilized and the manner in which 
they are applied. In order that we may adequately understand the prin¬ 
ciple of this type of therapy, we should clearly define what is meant 
by the term occupational therapy and by the associated terms above- 
mentioned. 

Occupation is work. Work used to improve either the physical or men¬ 
tal functions of a patient is occupational therapy. Ergo therapy is work 
therapy and hence synonymous with occupation therapy. 

Functional reeducation, as used in conjunction with restoration of 
those physically maimed, is the physical restoration of function, by means 
of appropriate physiotherapy, such as baking, hydrotherapy, massage, elec¬ 
tricity or gymnastics. Where a remedial exercise is given in the curative 
workshop through the movements required in carrying out definite trades 
or occupations, this type of work borders closely upon occupational therapy. 
In a monograph on Occupational Therapy Applied to the Restoration of 
Function of the Disabled Joints, Baldwin states that “occupational therapy 
is based on the principle that the best type of remedial exercise is that 
which requires a series of specific voluntary movements involved in the 
ordinary trades and occupations, physical training, play, or the daily 
routine activities of life.” In this the author has limited occupational 
work to those suffering from disabled joints, hut a broader conception 
of its usefulness must be appreciated. Functional reeducation, if ap¬ 
plied to the restoration of disabled joints and accomplished through the 
medium of exercise in the curative workshops, is certainly occupational 


268 


OCCUPATIONAL THERAPY 


therapy, for not only does the patient functionally improve the range of 
motion in his joints, but he receives a training in mental coordination 
which, if anything, is of more permanent value than the physical restora¬ 
tion. However, there are many cases totally unsuited for w T ork in the 
curative workshops which can be reached and benefited by occupation 
appropriately applied. 

Kehabilitation therapy, as its name implies, may include both the 
physical rehabilitation and the vocational rehabilitation, and for this 
reason is a rather confusing term. Vocational rehabilitation, or voca¬ 
tional training, is the training of one physically or mentally below par, 
in work by means of which he will later be able to make his livelihood. 
Physical rehabilitation, on the other hand, includes all the medical, sur¬ 
gical and physiotherapeutic means for the restoration of function in a 
patient and should not be confused with occupational therapy. 

If one appreciates that occupational therapy is applied to those 
chronically ill, or maimed, as an adjunct in improving their physical and 
mental well-being while disabled, either by means of curative workshops 
or by less active work at looms or in bed, and that the advancement made 
as the patient improves physically is in the taking up of vocational train¬ 
ing and fitting him for suitable work as a means of earning a livelihood, 
a more definite understanding of the principle and purpose of occupational 
therapy will be obtained. 

The selection of work suitable for a patient may vary from the 
cutting of paper puzzles in bed to the use of the electric torch in acetylene 
welding, but it is, nevertheless, work, requiring a varying degree of 
mental and physical coordination on the part of the patient, and it is the 
beginning of the training in mental or physical coordination that dig¬ 
nifies the work accomplished as occupational therapy. 

r* 

TYPES OF REMEDIAL WORK 

Work, as a remedial agent, varies in the type of case in which it is 
used, as well as in the stage at which it is started. One might divide 
such work into three stages, as follows: 

1. Occupation for those bedridden. 

2. The intermediary stage, or occupation for ambulatory cases re¬ 
quiring hospitalization. 

3. Vocational training. 

Among the bedridden, it is generally understood that those acutely ill 
require rest and are not benefited in any way by attempts at even diver- 
sional occupation. But there are many bedridden patients among chronic 
cardiacs, tuberculous cases and hopeless cripples, interested in work which 
they are able to do and which stimulates and endows them with a spirit 



TYPES OF REMEDIAL WORK 


209 




Fig. 1.—Rake Knitting and Tapestry Making. 

of hopefulness and of accomplishment that can be gained in no other 
way. The dissatisfaction of being unoccupied in bed offers time for 


Fig. 2.—Beet Making. 

thought and introspection and complaint concerning the unfortunate’s 
condition. The improvement in the powers of coordination, the lessening 
of the introspection and the requirement of fixing the attention to the 









270 


OCCUPATIONAL THERAPY 


work at hand engenders an improved spirit with the desire of accom¬ 
plishment in those kept occupied. Suitable occupation requires thought 
in selection. The previous mental status of the patient, his age, present 
physical condition, likes and dislikes and personality must be considered, 
but once a suitable means is found, the effect produced will warrant the 



Fig. 3.—Basket Making While Confined to a Wheel Chair. 


effort spent in finding it. Following is a short list of occupations suitable 
for those confined to bed: 


Puzzles. 

Chip carving. 
Modeling. 

Making flowers. 
Basketry. 
Crocheting. 
Knitting. 

Belt making. 
Small loom work. 


Stencil work. 
Metal work. 
Leather work. 
Drawing. 
Designing. 
Painting. 
Embroidering. 
Reading. 
School work. 




TYPES OF REMEDIAL WORK 


271 




Fig. 4.—Braiding Rugs While Convalescing. 

The intermediary stage, comprising by far tbe greatest number of 
patients who are benefited most by suitable occupation, includes that large 


Fig. 5.—Weaving on Hand Looms in the Ward. 

class of patients requiring institutional treatment but not actually con¬ 
fined to bed. In every surgical ward, in many medical wards, in all 
orthopedic institutions or services, and in convalescent and tuberculous 





272 


OCCUPATIONAL THERAPY 



Fig. 6.—Rug and Table Cover Weaving and Painting for Ambulatory Cases. 

homes, great numbers of patients are to be found who respond admirably 
to the stimulus of work. The choice of a suitable occupation for these 



Fig. 7.—Jig-saw Work for Ambulatory Cases. 

people is extremely important. As Barton has pointed out, a hammer 
may vary from the small jeweler’s hammer, which may be strapped to a 







TYPES OF REMEDIAL WORK 


273 


finger, to the blacksmith’s sledge; so that ordering work with the use of 
a hammer would be as ill-advised as the prescribing of a tonic, and leav¬ 
ing it to the patient to administer to himself any stimulant he might 
think necessary. 

At times, patients will resent doing the diversional forms of occupa¬ 
tion, and will respond admirably to the stimulus of curative workshop oc¬ 
cupation when it has been explained to them that the use of certain tools 
or machines, when used as directed, will help the stiffened hand or weak¬ 
ened leg. Most patients, however, respond to the creative idea of pro¬ 
ducing something, and once they can be interested in the production of an 



Fig. 8.—Scarfs, Table Covers, Baskets, Toys, Etc., Products of 
Occupational Therapy. 


article, it is difficult to draw them away from it until it is finished. They 
must be carefully watched, as patients recently out of bed will often 
fatigue themselves at the beginning of their work, so that it is very diffi¬ 
cult to get them to return to it. Many forms of occupation have been 
made applicable to this class of cases, and the more experience the director 
of this work has, the greater diversity of occupations he will find suitable 
for them. 

The space allotted to the work within the confines of hospitals varies, 
in different institutions, from the equipment that may be kept in a ward 
to whole buildings of curative workshops, hut the same principle of sus¬ 
tained effort may be secured from the humblest equipment as from the 

most elaborate. 

Occupations for ambulatory cases may be selected from the following 




274 


OCCUPATIONAL THERAPY 


list which have been found suitable in many different institutions utilizing 
occupation as a remedial agent: 


Loom work (making small blankets, rugs, table-covers, scarfs, bags, 


etc.). 

Basketry. 

Cabinet making. 
Bookbinding. 

Leather work. 
Hammered brass work. 


Jewelry work. 
Pottery. 

Cement work. 
Light gardening. 


Salmon gives the following as equipment for the beginning of a cura¬ 
tive workshop: 


Smith shop 

Forges, tools, etc., for 10 men. 

Fitting shop 

1 screw cutting lathe. 

1 sensitive drill. 

1 polishing machine. 

1 electric motor (IV 2 horse 
power). 

Swages and tools for 8 men. 

Leather blocking 
Sewing machine. 

Eyeletting machine. 

Tank. 

Galvanized iron and tools. 

Tailor’s shop 

3 sewing machines. 

Tools for 10 men. 


Carpenter shop 

Selected tools for 15 men. 

Bench screws. 

Special tools not for general use. 
Woodturner’s lathe. 

Machine shop 

Electric motor (8^ horse power). 
Shafting. 

Brackets, etc. 

Cement shop 
Metal molds. 

Tools for 12 men. 

General 

Drilling machine. 

Grindstone. 

Screw cutting lathe. 

Fret-saw worker’s machine and 
patterns. 

Circular saw bench. 


When a patient, physically handicapped through accident or disease, 
is forced to abandon the thought of return to his previous occupation, he 
is faced with the problem of finding some work which he will be able to 
do. Ordinarily this would mean either working for a lower wage, or for 
less time, either of which would mean a decreased income, lower standards 
of living and discontent. All who have seen patients pass through this 
change realize the marked psychological change such individuals undergo, 
and yet there are but few for whom profitable productive occupation 
cannot be found, if they are able to get about and still possess the desire 
to work. 

To do this, the problem of vocational training must be started in the 
hospital. Occupational therapy, used intelligently, instills into the patient 
the necessity for continuance of productive activity and prepares the way 
for vocational training. The standardization of equipment, the selection 


TYPES OF REMEDIAL WORK 


275 



Fig. 9.—Printing Shop at the Dover Farms Industries, New York, Where Voca¬ 
tional Training Rehabilitates the Crippled and Disabled. 



Fig. io.—Fly Shuttle Hand Looms at the Dover Farms Industries, New York. 




















276 


OCCUPATIONAL THERAPY 



of standard design, used during the ambulatory stage, will do much to 
shorten the preparatory lessons in a vocational school. 

Institutions like the Red Cross Institute for Crippled and. Disabled 
men, and the Dover Farms Industries in New York, are to-day practically 
solving the vocational problems of hundreds of physically handicapped 
men. The former institution, after a thorough study of many occupations, 
aims to train the handicapped individual in an occupation suited to his 
requirement, whereby his handicap is minimized. The Dover Farms In¬ 
dustries maintain a city center, where the handicapped are trained in 
productive occupations, paying the individual on production. They also 


Fig. 11.—Rug Making at the Dover Farms Industries. Three cases of amputation 
of extremities are shown. 


maintain a farm where handicapped men may he kept for an indefinite 
period, where weekly wages remunerate the individual’s efforts in con¬ 
genial surroundings. Whether the method of rehabilitating the handi¬ 
capped by adjusting an existing position in industry to his needs, or 
whether the method of grouping the handicapped in a community and 
having the total production provide a livelihood for each member of the 
community, is the better, can only be found by meeting each individual’s 
problem in the most sensible, way so as to permit of time’s economic ad¬ 
justment of the problem. , 

Application of Work.—The most important factor in the application 
of this form of work lies in the qualifications of the director of occupa¬ 
tional therapy. Such a director must possess a deep interest in this 





TYPES OF REMEDIAL WORK 


277 


subject in order that he may be able to arouse the interest of his pa¬ 
tients. The suggestion, by a tactless director, that it is time for a con¬ 
valescent patient to go to work, frequently arouses an antagonism on the 
part of the patient against any form of occupation which is difficult to 
overcome. On the other hand, the more versatile,' tactful director will 
first interest himself in the patient’s everyday psychology, finding out his 
likes and dislikes and, having become somewhat acquainted with him, 
suggest that they do something together—the most reasonable approach 
and one most frequently assented to by the patient. 



Fig. 12.—Vocational Rehabilitation at the Dover Farms Industries’ Cabinet Shop. 


The type of patients in the orthopedic hospitals differs materially 
from that found in hospitals for mental diseases, and the approach to a 
patient in each instance will vary. The more versatile the director, the 
easier it will be for him to suggest an occupation suitable to the patient’s 
requirements. It is as harmful to start a patient on a piece of work 
that is difficult for him as it is to order an overdose of strychnin. The 
director should, moreover, possess an unbounded patience, a vast amount 
of energy, an appreciation for effort, even in such cases where the product 
of the patient’s efforts is hopeless from a commercial point of view. The 
accomplishment of producing even a poorly made article, where the ef¬ 
fort is appreciated, frequently will stimulate the patient to further effort 





278 


OCCUPATIONAL THERAPY 


and awaken an interest in the work which grows into a desire to return 
to regular occupation. 

The application of occupation requires time, of which the average 
convalescent, or chronically ill patient, has an abundance. It is time in 
which the patient is wealthy, and whereas commercial articles to be salable 
must be turned out in the greatest of numbers in the shortest space of time, 
the product of the occupational therapy department should be one whose 
value is based on its excellence of work in order to compete with the 
commercial market. A well-done piece of hand-hammered brass has a 
market which cannot be infringed upon by the machine-made article, and 
the monetary value of such an article is measured only by its excellence. 
It is important, therefore, that 

1. Useful articles be produced. 

2. Articles be produced for which a market exists. 

3. Effort be made to produce articles which, because of their ex¬ 
cellent workmanship, form and color, are to be commended. 

The space required for the application of the work will vary accord¬ 
ing to the type of institution in which it is used. Whereas, in the tuber¬ 
culosis hospitals much of the work will be done in bed, the requirement 
for space, other than for small storage rooms, is not great. However, 
in the orthopedic institutions, or in the general hospital or surgical services, 
the curative workshops require space for small machinery, for large looms 
and for different types of work which cannot be dispensed with. A small 
beginning usually leads to more extensive plans than were formerly 
thought of, so that, in beginning such a department, sufficient space should 
be allowed for natural development. In the Reconstruction Hospital in 
New York, where industrial accidents and diseases are cared for, one en¬ 
tire floor of an eleven-story building, now in the course of construction, 
is to be devoted entirely to occupational therapy. 

The financing of a department of this kind is frequently one of the 
objections raised in starting such work. Like all other departments of a 
hospital, it requires money to run it. Some institutions have appropriated 
a small sum to start the work, placing in charge of the department an 
experienced occupational teacher who works under the direction of a 
medical adviser. As assistants to the teacher, volunteer aids can be se¬ 
cured, who will give part of their time to the teaching of the different 
crafts. As products materialize in the department, the assistants dispose 
of them through sales, bazaars or through commercial houses, who sell the 
articles on a commission basis. The cost of the material is deducted 
from the selling price, the patient receiving the balance for his work. In 
other institutions, the patient makes one article which he is permitted 
to sell for himself on condition that he produces another like article for 
sale by the institution. Still other institutions have a fixed price, which 
is given for the work produced, the institution disposing of all articles 


TYPES OF REMEDIAL WORK 


279 


at its own price. The choice of method of disposition of the articles is, 
however, not the most important phase of the work, and is usually met 
with in some way by the director of the department. The effect, how¬ 
ever, on the patient of securing monetary return for his efforts cannot 
be dispensed with, and, to my mind, is an important factor in readjust¬ 
ing him and hastening his return to more profitable employment. 

The National Society for Promotion of Occupational Therapy has re¬ 
cently stated the following basic principles of occupational therapy: 

1. Occupational Therapy is a method of treating the sick or injured by 
means of instruction and employment—productive occupation. 

2. The objects are to arouse interest, courage and confidence; exercise mind 
and body in healthful activity; overcome functional disability, and reestablish 
capacity for industrial and social usefulness. 

3. In applying occupational therapy, system and precision are as important 
as in other forms of treatment. 

4. The treatment should be administered under constant medical advice 
and supervision, correlated with other treatment of the patient. 

5. Treatment should in each case be specifically directed to the individual’s 
needs. 

6. Although some patients do best alone, employment in groups is usually 
desirable, because it provides exercise in social adaptation and stimulating influ¬ 
ence of example and comment. 

7. The occupations selected should be within the range of the patient’s esti¬ 
mated interests and capabilities. 

8. As the patient’s strength and capability increase, the type and extent of 
occupation should be regulated and graded accordingly. 

9. The only reliable measure of the value of treatment is the effect upon 
the patient. 

10. Inferior workmanship, or employment in an occupation which would 
be trivial for the healthy, may be attended with the greatest benefit to the sick 
or injured. Standards of entirely normal persons must be maintained for the 
proper mental stimulation. 

11. The production of a well-made, useful and attractive article, or the accom¬ 
plishment of a useful task, requires healthy exercise of mind and body, gives 
the greatest satisfaction and thus produces the most beneficial effects. 

12. Novelty, variety, individuality and utility of the products enhance the 
value of an occupation as a treatment measure. 

13. Quality, quantity and salability of the products may prove beneficial, 
by satisfying and stimulating the patient, but should never be permitted to 
obscure the main purpose. 

14. Good craftsmanship and ability to instruct are the essential qualifica¬ 
tions of the occupational therapist. Understanding, interest in the patient and 
an optimistic cheerful outlook and manner are equally essential. 

15. Patients under treatment by means of occupation therapy should also 
engage in recreational or play activities. It is advisable that gymnastics and 
calisthenics, which may be given for habit training, should be regarded as work. 
Social dancing and all recreation and play activities should be under the definite 
head of “recreations.” * 

3 Maryland Psychiatric Quarterly, January, 1919. 




280 


OCCUPATIONAL THERAPY 


REFERENCES 

Barton, George E. Teaching the Sick, W. B. Saunders Company, 
Philadelphia, 1919. 

Dunton, William R., Jr. Reconstruction Therapy, W. B. Saunders 
Company, Philadelphia, 1919. 

Hall, Herbert J. The Work of Our Hands, Moffatt, Yard & Company, 
New York, 1915. 

- : -Handicrafts for the Handicapped, Moffatt, Yard & Company, 

New York, 1919. 

-Wheel Chair Occupations, published under the auspices of the 

Institute for Crippled and Disabled Men, 1919. 

Red Cross Institute for Crippled and Disabled Men, Reports, 1915-1920. 

Salmon.* Psychiat. Bull., ii, 355. 

Slagle, Eleanor Clark. History of the Development of Occupation for the 
Insane, Psychiat. Quart., Maryland, July, 1914. 

Tracy, Susan E. Invalid Occupation, Whitcomb & Barrows, Boston, 
1910. 




CHAPTER VIII 


ELECTROTHERAPY 
Harry Eaton Stewart 

GALVANIC OR CONSTANT CURRENT 

Sources. —Galvanic electricity may be obtained from the town lighting 
supply, which, if alternating in type, must be changed over by motor trans¬ 
formers. It may also be derived from power generated on the premises, 
or from the chemical action ofacells or batteries. Some one of these sources 
of current is always near at hand. 

Apparatus. —It has seemed to the writer that too much space has been 
given by authors on electrotherapeutics to a detailed description of ap¬ 
paratus. The physician is now able to obtain a number of well-constructed 
types of galvanic machine. The leading manufacturers are providing 
service to keep such apparatus in working condition, therefore it would 
seem that emphasis should be placed upon the physics, physiological effects, 
indications and technic rather than upon any detailed description of ma¬ 
chine construction. 

Physics. —A very brief sketch of the physics involved in the galvanic 
current is necessary to the understanding of its physiological effects and 
will serve as a basis for the comprehension of the other types of current. 
The earth contains a certain amount of electricity, which amount is 
taken as the standard for comparison with the amount contained in other 
objects. An excess of that contained in the earth might be considered 
as “higher potential” or a positive charge and will flow to the earth when 
a body so charged is connected to it by a conductor or ground, and the 
flow will continue until the electrical charge of the body is equal to 
that of the earth. Electricity will pass from a body charged with a 
higher potential to one with a lower potential when so connected, until 
the charge in each is equal. When we desire this flow or current to be 
constant we must find some means of creating and maintaining a differ¬ 
ence in potential. This may be accomplished through chemical action in 
the galvanic cell, or by mechanical action in the dynamo. The simplest 
form of generating an electric current is in the single cell, which will 
now be described. 


281 


282 


ELECTROTHERAPY 


Galvanic Cell. —This consists of a container partially filled with 
dilute sulphuric or hydrochloric acid, termed the electrolyte, into which 
is placed a rod of zinc and a rod of carbon or copper. Chemical action 
is at once set up, the acid reacting upon the zinc with the formation of 
new chemical substances, among them zinc sulphate and hydrogen. Some 
of these elements travel toward one pole and some toward the other, ac¬ 
cording to tneir electrical affinity. So long as this chemical action of the 
acid on the zinc pole continues, the principal movement of elements 
toward the carbon or copper pole is maintained, charging it with a higher 
potential, and it is therefore designated as the positive pole, the zinc be 
coming the negative. If to these poles outside of the cell a conducting 
wire is attached, an electrical current will flow from the positive to the 
negative poles, thus completing the circuit. Thus it is seen that the 
difference in potential within the cell constantly created by chemical 
action is equalized by the flow of current along the wire. When this 
chemical action becomes weaker or ceases, there is a corresponding weak¬ 
ness and cessation of the current outside of the cell. The dry cells 
follow the same principle of construction except that the electrolyte is 
made of some solid or semisolid substance and the container is of un¬ 
breakable material. 

Batteries. —To obtain more power than can be generated in a single 
cell, two or more may be connected together to form what is known as 
a battery. In medical practice we usually desire high voltage and low 
amperage; to obtain which, the cells must be connected in series. In 
this case the positive pole of one cell is connected with the negative pole 
of the next cell and so on to the desired number. In this way the am¬ 
perage remains that of one cell, but the voltage is multiplied by the number 
of cells connected. Occasionally, however, high amperage is desired 
rather than high voltage; the cells are then connected in parallel, that 
is, all the positive poles are joined together to form one terminal and all 
the negatives to form the other. 

Electrical Terms. —The simplest definition of the various terms met 
Avitli in studying this subject should be constantly kept in mind. Among 
them are: 

Volt .—The unit of pressure of electromotive force generated by the 
standard wet cell. (V.) 

Ohm .—The amount of resistance offered to the passage of a current 
through one thousand feet of one-tenth inch copper wire. (R.) 

Ampere .—The quantity of current which the force of one volt will 
drive through one ohm in one second. Since in medicine we usually deal 
with a small quantity of electricity, we commonly use one one-thousandth 
of this amount or the milliampere (m.a.) as our standard. 

Ohm's Law .—In an electric circuit the strength of the current ig 


GALVANIC OE CONSTANT CURRENT 


283 


inversely proportionate to the resistance. The quantity of current (am¬ 
peres), C, is equal to the electromotive force (volts), E, divided by the 
resistance (ohms), R, or C equals j|. No more simple way can be 
found to illustrate these terms than by comparing the flow of electricity 
to that of water. Let us suppose that we have two containers con¬ 
nected by a pipe, each partially filled with water. If one is above 
the level of the other, the water will flow from the upper to the lower 
container. The difference in the level illustrates the difference in electric 
potential, and the quantity of water which flows through the pipe repre¬ 
sents the amperage. The speed or pressure of the flow would correspond 
to the voltage, while the resistance offered by the walls or turns in the pipe 
resembles the olnnage in an electric circuit. 

It is stated in Chapter XII that the constant current is the one 
whose main effect is chemical. Eor all practical purposes the slight 
thermal effect can be disregarded. When the galvanic current is passed 
through bodies complex in their chemical make-up, such as human tissue, 
chemical changes immediately take place. Complex molecules are dis¬ 
sociated and new combinations formed from their elements. Atoms 
become electrically charged and the ions already in the tissues begin a 
movement across the electric field or pathway according to their different 
affinities. As will be later shown, these chemical effects, produced by the 
passage of the galvanic current through the tissues, are what determine 
its employment in therapeutics. They are complex and many of them 
relatively unimportant, but the important and useful chemical changes may 
be used advantageously and the others disregarded. 

Physiological Effects. —The chemical changes just referred to may 
be brought about within the living body almost as easily as outside of 
it. It must be clear that we are dealing with a powerful agent by means of 
which to effect tissue processes. Indeed, within its very .evident limita¬ 
tions we have the advantage of more direct and more easily localized 
effect than is possible with drugs by internal administration. Since the 
ions within the tissues do move according to their selective polar affinity, 
it must be evident that the selection of the proper pole is absolutely 
essential and the differential effects must be clearly understood. The 
importance of this cannot be overestimated, for, as might be inferred, 
in most conditions where the application of the positive pole is indicated, 
the negative would be distinctly harmful, and vice versa. The selective 
action of the galvanic pole upon drug ions will later be taken up. The 
effects which they exert upon living tissue are as follows: 

Positive pole. 

1. Produces vasoconstriction. 

2. Is sedative to sensory nerve endings, relieving pain. 

3. Hardens newly formed tissue, especially scars. 


284 


ELECTROTHERAPY 


Negative pole. 

1. Produces vasodilatation. 

2. Is both stimulating and irritating. 

3. Softens and reduces the amount of scar tissue. 

Polarity Tests. —Fill a glass partially full of salt solution; a 1 or 2 
per cent solution as ordinarily used on all galvanic electrodes is suffi¬ 
ciently strong. The galvanic machine is then connected up, with the 
metal cord tips firmly fastened at the terminals on the machine. Turn 
on a moderate amount of current and allow the other tips of the two 
cords to drop into the solution about a half inch apart. Very soon 
bubbles will be seen on one of the metal tips. This is the negative 
pole. Another test is to apply the cord tips to moistened pink litmus 
paper, when a blue stain will appear at the negative pole. It should 
be remembered that, with several types of wall plugs, the polarity on 
the apparatus may become reversed; therefore, such a machine should 
be retested for polarity each time after it is connected up to the current. 
Where central contact plugs are used, or it is not necessary constantly to 
disconnect the machine, the terminals into which the cord tips arc inserted 
may be permanently marked, as the polarity will not change. 

The resistance of the human dry skin is about five thousand ohms; 
we moisten the skin with saline in order to reduce this resistance as much 
as possible. 

Therapeutic Uses of Galvanic Current. —In therapeutic practice the 
galvanic current may be employed to: 

1. Introduce drugs into the tissues—so-called medical ionization. 

2. Relieve local or general fatigue by removing waste products through 
the rearrangement and redistribution of ions already in the tissues. 

3. Destroy tissue through the formation and concentration of caustic 
elements at the point of entrance or exit of the current—surgical ioniza¬ 
tion. 

4. Alleviate pain through sedative effect upon sensory nerve endings. 

5. Produce muscular contraction when used in its interrupted, wave 
or sinusoidal form. 

6. Stimulate the central nervous system. 

7. Reduce the size of hypertrophic and adventitious tissue within 
certain definite limitations. 

The subjects of medical and surgical ionization will be taken up and * 
discussed under their separate headings. The relief of local and general 
fatigue is accomplished in this manner. As soon as the galvanic current 
is passed through the tissues, there is at once instituted a movement of 
certain of its elements or ions. Those carrying a positive charge move 
in the direction of the negative pole, while those negatively charged seek 


GALVANIC OR CONSTANT CURRENT 


285 


the positive pole. Certain complex productions are broken up by an 
electrolytic process and when dissociated the newly liberated ions also 
start a definite migration following the same principles. 

New elements then formed have a modifying effect upon the tissues. 
During their passage through the tissues many of these elements are 
swept away in the blood and lymph channels, through which they at¬ 
tempt to make their way, and thus their elimination from the body is 
hastened. Clinically the result of this process is sensed by the marked 
relief from fatigue in any given locality after a few minutes’ application 
of the galvanic current. Pain is lessened by the sedative effect of the 
steady movement of certain ions in the vicinity of the sensory nerve 
endings, those attracted to the positive pole predominating in this effect. 
The slight tingling or stinging sensations that are produced when the 
galvanic current is applied are, undoubtedly, due to this fact. There 
is no doubt that the sudden starting of such ionic movement through the 
motor nerve endings causes the preliminary contraction, or twitch, which 
the muscle gives when the galvanic circuit is closed or made. The steady 
movement of these ions when the current is kept at even strength does not 
cause any further muscle contraction. When, however, the strength of 
the current is suddenly changed or the current is turned off, there results 
another muscle twitch. Therefore, we may assume that, in order to 
produce a muscle contraction in the vicinity of either pole, it is necessary 
to bring about an abrupt starting or stopping of ionic movement. If the 
current is reversed very slowly, we obtain a response from the sensory 
nerve endings as the result of the movement of the ions, first in one 
direction, then in the other. When, however, this reversal is abrupt, the 
ionic movement will result in a stimulation to the motor nerve endings 
and the muscle substance, which results in a contraction. The more rapid 
the reversal of polarity or the application and removal of the current 
becomes beyond the number of fifty or so per second, which is physiological, 
the less vigorous will be the muscle contraction responses. When these 
changes reach a frequency of approximately five hundred per second, 
no relaxation time is allowed and the muscle becomes tetanized. As 
we shall see in the study of high frequency currents, when these changes 
are increased to over ten thousand per second, the ions remain practically 
stationary, there being more time for appreciable movement in either 
direction, and, as we would expect, all motor responses on the part of the 
muscle cease from that point on. 

As might be expected, there is a difference in response to current 
variations at the two poles. At the region of the positive pole, or anode, 
there is a decrease in irritability and a lessened contractile response, 
while at the negative pole, or cathode, the irritability is increased and the 
contraction more marked. The stimulation of the central nervous sys¬ 
tem may be brought about by a removal of the fatigue products in the 


286 


ELECTROTHERAPY 


same manner. The slight improvement in the circulation which it is 
possible for us to obtain does not account for the sum total effect of 
stimulation we are able to procure. For instance, in galvanism of the 
brain there must be, in addition, a distinct increase in the metabolism 
of the individual neurons of the central nervous system. 

Tkeatment 

Technic. —All the switches on the apparatus should be turned off, 
the wall plug inserted and the machine examined to see that all connections 
are tight. The cords should next be attached to their terminals and should 
constantly be watched to see that they are in good condition. The 
frequent soaking of the ends of the cords for polarity testing and treatment 
is apt to rust even the best material of which their metal center is made. 
A break in the wire is not usually visible through the covering, but, 
if present, will interfere absolutely with the success of the treatment. 
The polarity should then be tested by either of the methods above given 
and the cords marked so that they will not become confused. 

Electrodes.— Electrodes of the proper size and material should be at 
hand, sterilized if possible. In selecting the proper electrodes to be used 
the following points should be kept in mind: 

1. The indifferent electrode should be, roughly, double the size of 
the active electrode, and it may be placed in any convenient position, 
usually a short distance centrally and opposite to the latter. 

2. The size of the active electrode depends upon the area which it 
is desired to treat, and it is placed in the closest possible proximity to that 
area. 

3. The strength of the current desired must also be considered in 
determining the size of the active electrode, because it is not safe or 
comfortable to use more than 1% milliamperes of current per square 
inch of this active (smaller) electrode. 

4. The shape of the electrode is also determined by the area to 
be treated. For instance, in a treatment over the sciatic nerve an 
electrode very long and narrow should be selected. 

Most of these electrodes are constructed with a metal screen back, to 
which the cord tip insert is soldered and to the face of which felt or other, 
soft covering is attached. This metal screen back may rust and break, 
with the result that an undue concentration of current is applied to the 
patient, if the size of the felt has been taken as the gage for determining 
the proper current strength. Many of these heavy felt coverings take a 
considerable time to soak through and properly transmit the current. 
They should never be placed on end to dry, as gravity will produce an 


GALVANIC OR CONSTANT CURRENT 


287 


uneven degree of moisture, while they still seem wet enough to reapply 
without soaking. When the small disc electrodes are used with a hooplike 
metal rim they are apt to become concave and the patient receive a con¬ 
centration of current from the rim rather than from the whole electrode. 
I hey must be kept flat by cotton, or a suitable covering of gauze. 
Where gauze is used as the covering, not less than twelve to fifteen layers 
should be applied. In the application of electrodes to patients it is 
advisable to have plenty of absorbent cotton at hand. This may be cut 
into sizes slightly larger than the electrodes, well soaked in saline and 
then placed on the skin with the electrodes over them. These pieces of 
cotton may be discarded after each treatment, thus obviating the necessity 
of sterilizing the electrodes themselves. 

The Patient. —If the patient is appearing for the first treatment, it is 
well to explain to him, briefly, something of the nature of the treatment 
and the sensation he will experience. It is quite usual to find that patients 
at first fear “electric shock” and will not properly relax unless mentally 
prepared and made comfortable. On the treatment table, the part to be 
treated must be well supported and the patient should be able to relax 
perfectly. Blankets, rubber sheeting or bath towels should be provided 
to keep the patient warm and his clothing dry. Next, the skin covering 
the areas where both the active and indifferent electrodes are to be 
applied should be carefully examined. All evidence of ointments, oils, 
liniments or other applications, when found, should be removed by 
soap and water, or alcohol. Some of these substances are apt to facili¬ 
tate skin burns and all oily media are poor conductors of electricity. 
If any abrasions are found, they should be covered with dry gauze and 
adhesive plaster. The electrodes of proper size and shape having been 
selected and thoroughly soaked in a 1 or 2 per cent saline solution, they 
are ready to be applied. The pads of absorbent cotton are soaked in the 
same solution, the excess of moisture gently squeezed out, and placed 
evenly on the skin. The electrodes are applied over them, the appropriate 
cord tip inserted and the whole bound snugly on with elastic webbing, 
except in such positions as the back of the shoulder, where the patient may 
conveniently lean against the electrode, thus holding it in place. A 
bath towel may be bound on or held by the patient to keep the electrode 
in place. In any event a perfect contact must be made to prevent bums. 
Everything is now ready for the treatment. The current should be turned 
on slowly and the operator should watch the patient as well as the meter. 
When a stinging sensation is felt by the patient, it is well to wait a few 
minutes before raising the current to maximum. Whenever this sensation 
is excessive and the current strength is not too great in proportion to the 
size of the smaller electrode, the current should be turned off slowly 
and the patient’s skin examined for possible abrasions which were over¬ 
looked. 


288 


ELECTROTHERAPY 


If the treatment is to continue for longer than twenty minutes, unless 
a good thick cotton pad has been added, the electrodes should he re¬ 
moistened to prevent excessive skin irritation. This irritation is caused 
by a concentration of salts at the applied poles. These do no harm if kept 
in proper solution by sufficient moisture of the electrodes. On the other 
hand, if the electrodes become dry, a severe irritation of the skin may 
result, which may prevent further treatment for several days. At the end 
of the time prescribed the current is turned slowly, gradually and com¬ 
pletely off. The electrodes are then removed and the patient’s skin ex¬ 
amined, dried and dusted with talcum powder. There should be no more 
than a slight redness of the skin under the electrodes and a slight, com¬ 
fortable feeling of warmth in the parts treated. Electric burns are 
usually the result of metal touching the skin during the treatment. They 
are extremely hard to heal and are inexcusable. When they do occur 
they should he treated as any other burn. 

Precautions. — 1 . Patients should receive little, if any, sensation from 
the treatment. A slight tingling is all that is permissible. The meter 
reading alone cannot be depended upon. Occasionally, during the treat¬ 
ment, the meter reading will increase. This may he due to the fact that 
certain ions are being introduced which tend gradually to reduce the 
resistance of the skin and subcutaneous tissue to the passage of the current. 
More often the meter needle wall gradually return toward zero. This 
occurs when the skin is becoming dry or when certain ions, such as the 
metals, are being introduced which form insoluble elements with the 
ions already in the tissues. 

2. As stated before, watch carefully for abrasions and, if found, 
properly cover them. 

3. In treatments about the head, especially in galvanism of the brain, 
it is very necessary to have a current of absolute steadiness. That derived 
from batteries or through water resistance is more safe than current taken 
from the main. The current must be turned on very slowly, never in 
large amounts, and the patient watched constantly for signs of distress 
or vertigo. Turning off the current at the end of the treatment must be 
done with equal care. 

4. In treating with the labile, or movable, electrode, it is better not 
to lift the electrode from the skin but to stroke firmly and rhythmically. 
Removing the electrode from the skin changes the treatment from that of 
constant to that of interrupted galvanism, with quite different results. 

5. Be particularly careful not to allow any metal to come in contact 
with the patient’s skin. Watch, especially, in this regard patients who 
are restless or who move the part under treatment in any way. 

6. Anesthetic areas, such as those covered by scar tissue and other 
skin areas just distal to scars, must be treated with extreme care. Keep 
in mind the unreliability of the meter reading. The important point is 


GALVANIC OE CONSTANT CUEEENT 


289 


that dryness of the electrode causes great skin resistance and the concen¬ 
tration of caustic elements, while there is a retrogression of the needle. 
There is also an increase in the unpleasant skin sensations which the 
patient experiences. In the anesthetic condition we are considering, he 
does not receive this sensatory warning and, therefore, we must be doubly 
cautious. It is well to use less current and shorten the time of the treat¬ 
ment, even to the point of getting less effect per treatment. 

7. If any adjustments of electrodes or of the patient’s body are re¬ 
quired, the current must be turned slowly and completely off before 
they are made. 

8. Erythema, other than a slight reddening, or increased sensitivity 
of the patient’s skin after treatment requires that these- conditions subside 
before further resumption of treatment. 

The Galvanic Bath. —The galvanic bath, both local and general, is 
becoming widely used. It has several advantages over the application of 
the current by means of the ordinary electrodes. In the first place, every 
square inch of skin immersed in the water becomes electrode surface, 
hence, relatively larger amounts of current may be applied with a mini¬ 
mum of disagreeable sensation. Secondly, perfect contact is of course 
assured and we do not have to watch for contact of metal to the skin or 
spend, unnecessary time properly to adjust the ordinary types of electrodes. 

Local Treatments. —These may be given in any container made of 
non-conducting material, such as porcelain or earthenware. Such con¬ 
tainers are manufactured of suitable size and shape to accommodate a 
single extremity. On the inside of the container is placed a plate of 
carbon or metal which extends down into the water and conducts the 
current from the cord to the fluid. An ordinary sponge electrode may 
be placed over the edge, or on the bottom, of the container, if this built- 
in-place electrode is not provided. The indifferent electrode may be 
another similar container or of the ordinary felt type, and applied over 
the lower back or behind the shoulder. To follow the principles already 
outlined, it would have to be a fairly large pad to equal or exceed in area 
the square inches of skin surface immersed. 

Schnee Bath. —This is a well-constructed series of four containers, for 
each of the extremities, two, three, or four of which may be connected up 
at the same time. The temperature should be 99° to 100° F., and kept as 
nearly as possible constant. There should never be any change made in 
the volume of water after the current has been turned on, as such change 
may result in sensations alarming to the patient. It is necessary care¬ 
fully to protect the clothing from becoming wet during the treatment. 
Bifurcated cords may be used, so that the positive and negative pole may 
be each applied to two containers at once. As in the other types of treat¬ 
ment, the current is turned slowly on and off, and the same slight tingling 
is a good guide to the amount of current to be used. 


290 


ELECTROTHERAPY 


General Galvanic Bath. —In general body treatments, there should be 
sufficient water in the tub to cover the body to the shoulders, and no 
change made in its volume once the treatment has been started. Occa¬ 
sionally, the sinusoidal or faradic, with or instead of the galvanic, may 
be given by the same technic for general tonic effect. Before the patient 
enters the bath, the temperature of the water should be tested by the 
attendant introducing his hand or elbow into it. The desired quantity 
of current may also be tested in this way, after which it is turned com¬ 
pletely off and the patient placed in the bath. A depressing or fatiguing 
effect follows too prolonged or too strong treatment and, on succeeding 
days, accordingly, it should be modified. The patient should never be 
left alone during the body bath treatment, as he is very helpless and, 
should any connection be loose or any change in the current flow occur, 
he may become frightened and the treatment end disastrously. Frequent 
inspection should be made of the apparatus and of its connections. 

General Galvanization. —In certain cases where the galvanic bath is 
impractical for any reason, a general treatment may be given by means 
of an especially constructed chair, which is usually of the reclining type, 
constructed with metal electrodes on the back, seat and arms. These 
plates are provided with fixtures to hold the tips of the cord from the 
apparatus. This chair is arranged so that one or more parts of the 
body may be treated at one time, though it is generally used for 
entire body treatments. The electrodes may be prepared as already de¬ 
scribed. When these treatments are given for sedative or mild tonic 
effect, the current should never be strong enough to produce more than 
slight tingling. To produce the greatest results in therapeutics, the 
galvanic current must be administered with carefully selected and in¬ 
dividual technic. It cannot be employed with best results in large clinics 
requiring hastily administered treatments to large numbers of cases. 


IONIZATION 

Definition. —Ionization, ionic medication or cataphoresis is the intro¬ 
duction from without, or the internal rearrangement or concentration 
within, the tissues of the ions of various chemical elements, by means 
of the selective polar action of the constant galvanic current. 

History. —Several physicists had suggested the possibility of utilizing 
this property of the galvanic current during the last years of the nine¬ 
teenth century. Leduc, of Nantes, in 1900, was the first to utilize ioniza¬ 
tion in the treatment of disease. Since that time there has been a rapid 
increase in its employment in therapeutics. W. J. Turrell, of England, 
has done very valuable work in clarifying and systematizing the physical 


IONIZATION 


291 


and chemical principles related to this subject, and G. Betton Massey, 
of Philadelphia, has made many valuable contributions to the literature. 

Chemistry. Certain acids, bases and salts in solution are broken up, 
by the passage of an electrical current through them, into atoms which 
take on different electrical charges. These are termed ions. These ions, 
or wanderers, are more or less unstable and enter easily into new chemical 
combinations. The term ion was first given to the electrified atom by 
Faraday. Leduc illustrates the action of the constant current in dis¬ 
sociating chemical bodies and their subsequent polar migration by com¬ 
paring the process to a dance. The partial association of the positive 
and negative ions is represented by the partners on the ballroom floor. The 
action of the passage of the current in separating and putting them in 
motion according to their electrical affinity is compared by him to the 
cessation of the music and the assembling of the ladies at one end of the 
room and the men at the other. 

Cations are ions containing a positive charge introduced at the 
positive pole, or originating in the pathway of the current, and traveling 
toward the negative pole. They include metals and hydrogen. 

Anions are those ions bearing a negative charge, which move toward 
the positive pole, and include chlorin, common bases and the hydroxyl 
group. 

Turrell emphasizes a point overlooked by many other writers on this 
subject, namely, that the chemical action at and immediately below 
electrodes is electrolytic in nature and is not the same as that which occurs 
in the interpolar pathway. The dissociated molocules in the ionic state do 
not exhibit their former chemical affinity which is temporarily replaced by 
the electrical charge. When they reach the immediate vicinity of the pole 
toward which they are attracted, they lose their electrical charge and 
again become chemically active as before. The velocity of movement which 
the various ions exhibit differs widely, hydrogen being by far the most 
rapid. Many of the effects we produce are due to the extremely rapid 
migration of the hydrogen and hydroxyl ions. The less the atomic weight, 
the faster will the ions travel. 

McGill quotes three experiments illustrating the importance of these 
polar effects: 

1. Fill a glass tube with absorbent cotton soaked in saline. At one 
end insert a small ping of cotton moistened with potassium iodid. In the 
other end place a similar plug wet with starch solution. Attach the 
cathode to the potassium iodid end and the anode to the starch end and 
turn on the current. The potassium iodid will be dissociated into its 
elements potassium and iodin, and the iodin will be driven toward the 
anode, where the starch will turn blue. Beverse the polarity and no such 
effect occurs. 


292 


ELECTROTHERAPY 


2. Paint two areas on a limb with tincture of iodin. Place a moist¬ 
ened electrode over each area and turn on the current. The brown stain 
will disappear under the cathode but not under the anode. 

3. Soak two electrodes in a solution of cocain hydrochlorid, apply 
to the skin and turn on the current. The skin over the anode will become 
anesthetic, that under the cathode will be unaffected, showing that it is 
not simple absorption of the drug but selective polar action which has 
occurred. . 

The belief that drugs are carried into living tissue is further proven 
by the appearance in the urine and saliva and by the deaths of animals 
with the use of the alkaloids. 

W. J. Turrell, in performing the starch and iodin experiment with a 
slightly different technic, calls attention to the fact that iodin ions are 
passed through a considerable quantity of starch, staining only that 
directly under the positive pole. Chatsky’s experiment tends to prove 
Turrell’s contention. A more complicated experiment, where strychnin 
sulphate was passed through the bodies of two rabbits, placed in circuit, 
further demonstrates this fact. The strychnin ion was not chemically 
active while passing through the first rabbit, but only when reaching 
the opposite pole in the body of the second rabbit did it lose its charge, 
become chemically active and cause the death of the animal. An attempt 
to pass the salicyl ion through a leg about to be amputated also failed to 
demonstrate the presence of the drug in the deeper tissues. Several 
American workers, including Massey, still believe that there is some ionic 
effect in the deeper tissues and they have obtained clinical results which 
it is hard to explain on any other basis. As many of the tissues we 
desire to affect are comparatively superficial and the condition of these 
tissues has been repeatedly improved by ionization, we may assume that we 
have a procedure of real clinical value. 

Turrell protests against the term ionization being employed to designate 
any given treatment, in the sense in which this term has commonly been 
used, stating that ionization is the dissociation of molecules in solution 
without the application of any external force. Although the point is well 
taken, the common use of this term to designate a method of treatment is 
followed rather than to introduce a confusion of terms. 

Technic. —The number of drug ions driven into the tissues will be 
proportionate to: 

1. The current density. 

2. The duration of the treatment. 

3. And inversely as the atomic weight of the ion used. 

The time factor is of the utmost importance. It requires from 30 to 
60 minutes of the application of a current of moderate strength to com- 


IONIZATION 


293 


plete a good ionization treatment. Moreover, it has been demonstrated 
that the best results are obtained by the nse of weak solutions of drugs, 
those of 1 or 2 per cent being preferred. 

Advantages of Ionization.—1 . The desired element of the drug is 
driven directly into the affected tissues instead of being scattered through 
the system in the circulation, where but a small proportion of it can 
exert its action on the affected area. 

2. The least desirable effects, such as those of the salicyl group upon 
the gastro-intestinal tract, are avoided. 

3. Drugs, such as cocain, may be applied without introducing the 
needle into the skin. 

Disadvantages of Ionization. — 1 . The greatest amount of ionizing 
effect takes place in the skin and subcutaneous tissue. 

2. The drugs which have, as yet, been successfully used are few in 
number. 

Treatments. —Under the cathode, or negative pole, we apply chlorin in 
the form of sodium chlorid, iodin from sodium or potassium iodid, and 
salicyl from sodium salicylate. Under the anode, or positive pole, we use 
zinc from zinc sulphate, magnesium from magnesium sulphate, lithium 
from lithium chlorid, silver from silver nitrate, copper from copper sul¬ 
phate and morphin, cocain and quinin. 

The directions and cautions given in the care and use of apparatus 
as outlined in the chapter on Galvanism are to be carefully carried out. 
The electrodes are selected and placed as for use in straight galvanic 
current. 

Typical Treatment. —Let us use, for an example, the ionization of the 
sciatic nerve for neuritis. 

A long, narrow, active electrode, which will extend from the sciatic 
notch to the popliteal space, is selected. A long, broad electrode, applied 
to the front of the hip and thigh, will serve as the indifferent electrode. 
They are both soaked in warm salt solution. A sufficient quantity of 
2 per cent sodium salicylate is warmed to about 100° F. A layer of 
absorbent cotton, large enough to extend beyond the active electrode in 
each direction, is immersed in the warm salt solution and the excess of 
saline gently squeezed out. The sodium salicylate is then poured over this 
cotton and applied directly over the course of the sciatic nerve. The active 
electrode is then placed over this and connected to the negative pole 
of the machine. Both electrodes are snugly bound on and the current 
slowly applied. We ordinarily use 8 to 10 milliamperes for about forty 
minutes. The current is then slowly turned off, the electrodes are re¬ 
moved and the skin is dried and powdered. 

Surgical Ionization. —By this term is meant the use of the polarity 
effect of the galvanic current to concentrate at a small localized point 
certain ions which actually destroy tissue. This destructive effect is 


294 ELECTROTHERAPY 

prevented in onr ordinary medical ionization by the size and moisture of 
the electrodes. 

The active electrodes used in surgical ionization are of metal only, 
and usually in the form of needles. The indifferent electrode used is the 
ordinary galvanic pad, which is placed a short distance from the part 
to be treated. 

For strong bactericidal effect upon infected sinuses, carbuncles and 
boils, blunt needles or rods of zinc are sometimes used as the positive 
pole. When so used, a pearly white color appears on the surface of the 
infected tissue and the bacteria count is greatly reduced. 

Steel needles should never be used, as they leave a black stain on the 
skin which is practically indelible. Platinum is the best needle material. 
Beside single needles, several may be used, inserted into one fixture. 

Technic .—The machine and different electrodes are prepared as for 
galvanism. The needle or needles are then inserted into the mass to be 
treated. When the current is turned on, a slight blanching of the skin is 
seen. As a rule, only a very slight amount of current is necessary to 
secure this effect. As soon as the blanching occurs, the needle should be 
withdrawn and inserted into a different part of the growth. The positive 
pole has a tendency to harden the tissues and the needle is difficult to 
remove. The time of the treatment in this case should be brief. This 
effect is not seen with the use of the negative pole, which softens tissue 
rapidly and in a few seconds the needle can be easily withdrawn. A 
typical example is the removal of superfluous hair. The light should be so 
placed as to shine directly on the hair follicles. A platinum needle is 
selected and connected to the negative pole. It is then inserted gently, fol¬ 
lowing carefully the direction of the hair root, as far in as it will pass 
easily, perhaps to the depth of one-eighth inch. The current is then 
turned on and increased to 2 or 3 milliamperes, while the needle is held 
steadily in place. In a short time, a number of small bubbles will appear 
at the root of the hair, then the current is turned off. The hair should 
then be withdrawn with forceps, without the use of any force. Not more 
than ten to twelve hairs, or one small growth, should be removed at one 
sitting in order to avoid unnecessary irritation to the skin and the pos¬ 
sibility of subsequent scarring. A strong current should not be used, as 
it is not any more efficient and may destroy more tissue than is intended. 

INTERRUPTED AND WAVE GALVANIC CURRENTS 

Interrupted Galvanic Current 

Sources. —Various devices have been perfected to interrupt the gal¬ 
vanic current. This may be done by means of a metronome, with the use 
of an interrupted handle electrode or by a key on the apparatus. The 


INTERRUPTED AND WAVE GALVANIC CURRENTS 295 


object of these devices is to secure a sharp, clear-cut make and break in 
the flow of the current through tissues, with the general object of induc¬ 
ing muscle contraction. 

Physiological Effects. —It was stated in our consideration of the 
galvanic current that it was the abrupt movement, or cessation of move¬ 
ment, of ions through the muscle and its motor nerve endings that induced 
contraction. As ordinarily used, the sharp interruption produces rather 
a muscle twitch than normal contraction. In normal muscle with its 
nerve supply intact the contractile responses are most sharp at that 
point, usually situated near the center of the belly of the muscle, termed 
the motor point. The phenomenon of the reaction of degeneration will be 
discussed under the heading of Muscle Nerve Testing. It may be briefly 
stated here that interrupted galvanism will produce contraction in muscle 
tissue even when its motor nerve is completely severed and a considerable 
amount of degeneration has taken place in the muscle itself. Such 
responses are no longer sharply localized at the motor point, but are 


Fig. 1.—Interrupted Galvanic. 

diffused throughout the muscle, sluggish and wavelike in character and 
with the normal polarity responses reversed. The application of a 
sufficient amount of interrupted galvanism to induce an approximately 
normal contraction would be sharp and unpleasant for the patient; there¬ 
fore, for treatment purposes, this type of current has been superseded by 
the wave or sinusoidal currents, next to be described. We obtain the 
muscular twitch whenever the current is abruptly started or stopped with 
use of either the negative or positive pole. When the current is started, 
made, or the circuit closed, the contraction is greater than when it is 
opened, or broken. As we would expect, the negative pole or cathode 
gives a more marked response; therefore, it is commonly stated that 
the cathodal closing contraction is greater than anodal closing contraction, 
or KCOACC in normal muscle. It must be remembered that occa¬ 
sionally the Tibialis anticus and Supinator longus are exceptions to this 
rule. 

Wave Galvanic Currents 

Sources and Apparatus. —There are several types of apparatus on the 
market which so modify interruptions of the galvanic current that they 
become regular and wavelike instead of abrupt. The term sinusoidal has 
at times been incorrectly applied to this type of current. A true wave 
current is one which rises from zero to maximum and returns to or 












296 


ELECTROTHERAPY 


nearly to zero and repeats in regular rhythm. The polarity once fixed 
does not change, therefore we are dealing with a series of negative or a 
series of positive waves. These waves of current may be varied in both 
voltage and amperage to a fine degree by recent improvements in ap¬ 
paratus. These variations are attained in the best type of machines by 
means of cams on a revolving drum, which make contacts of varying 
frequency, duration and intensity, between which there is a period of com¬ 
paratively no current flow. 



Fig. 2.—Slow Surging Galvanic. 


Physiological Effects. —The result of application of this type of gal¬ 
vanism to patients is simply a combination of those of straight and 
interrupted galvanism. The polarity effects of straight galvanism are pres¬ 
ent but, being intermittent and not continuous, are not as great in their 
total effects as with continuous current. On the other hand, the inter¬ 
mittent movement of ions through the motor nerve endings produces a 
rhythmical changing and fairly sustained stimulation which leads to good 
muscular contraction. It is a better current for treatment purposes than 
interrupted galvanism, but not as good for muscle testing. The care and 
application of electrodes follow the same general principles already out¬ 
lined. This current has proved of great value in the stimulation of atonic, 
but otherwise normal, muscle tissue, such as relaxed abdominal wall, and 
may be substituted within its limitations for sinusoidal or interrupted 
galvanism. 


SINUSOIDAL CURRENTS 

Definition. —A true sinusoidal current is one which alternates in per¬ 
fectly regular opposite and equal cycles or phases. The current strength 
rises from zero to maximum on the positive side and returns to zero, 



Fig. 3.—Slow Sinusoidal. 


followed by a similar rise and fall on the negative side, which may be 
plotted as a true sine curve. 

Physics. —An alternating current is conducted around the primary 
winding. This alternating primary current produces regular and even 
alternation in a secondary winding from which the patient is treated. 





SINUSOIDAL CURRENTS 


297 


The secondary winding reduces the voltage sufficiently for treatment pur¬ 
poses and might, therefore, he called a “step down” transformer. With 
the A.C. current also a somewhat similar arrangement is necessary to 
decrease both the voltage and the frequency of the current alternations.' 
It is evident that a current alternating rapidly enough for lighting pur- 

• f l/WVAAA/m 

Fig. 4.-—Rapid Sinusoidal. 

poses would be far too rapid to employ for the purpose of obtaining 
muscular contractions. 

Physiological Effects. —The sinusoidal current is one of the latest 
developments in electrotherapeutics and one of the most valuable for the 
following reasons: 

1. The gradual rise and fall in current strength and the evenness of 
the wave so produced is easily borne by the patient as compared to the 
faradic and interrupted galvanic currents. 

m m u 

Fig. 5.—Interrupted Sinusoidal. 

2. It has been proved that there is increased reaction when the 
negative pole is used where the positive has just been, or vice versa. 
This contrast is obtained in each cycle of the sine current, and gives 
it a distinct advantage over any form of simple wave galvanic current. 

Fig. 6.—Surging Sinusoidal. 

3. In a given time there is much less danger of overstimulation 
with this current than with the sharp and abrupt current of interrupted 
galvanism. 

4. A real stimulation of the metabolism of muscle tissue follows 
the application of this current, even when a perceptible contraction is 
not produced. 

There is no break in the current, that is, no distinct rest period 
and, because of its smoothness, a much larger amperage may be used than 





208 


ELECTROTHERAPY 


with the interrupted galvanic. This sine wave then is able to stimulate 
the muscle, even in a degree too small to produce a marked contraction 
and without the polarity effects of the galvanic current. It may be used 
for the purpose and to the point of obtaining a good contraction in a 
partially paralyzed muscle, but very few contractions are all that are 
permissible. 

Technic. —The care of the machine, especially the lubrication of the 
rotor control, is very important, if one desires to obtain a smooth, fine 
current. The part to be treated and the electrodes are prepared in the 
same way as for galvanism, the large indifferent electrode usually being 
placed opposite, and somewhat centrally, to the smaller testing or treating 
electrode. The mechanism of the machines, from their nature, must be 
intricate and delicate and they require more care perhaps than any 
machines which we use, except the static. 

Major C. M. Sampson, who had charge of perhaps the largest periph¬ 
eral nerve clinic in Army Hospitals, has perfected a technic which can 
scarcely be improved upon and which deserves a detailed description. 
The paralytic muscles are tested daily before the treatment and before 
receiving diathermy or whirlpool bath. The opposite limb, if normal, 
is tested for a control. 

Place the patient, and especially the limb to be tested, in a com¬ 
fortable position. During the test, the limb is placed on glass or wood 
covered by a towel or blanket. Test each motor point separately and 
compare it with the corresponding motor point on the normal limb. 
If both limbs are affected, another person may be used as the control 
at first. After sufficient experience this will not be necessary. After 
determining the motor point and marking it with a dermal pencil, use a 
small test electrode on the motor point, with both sinusoidal and inter¬ 
rupted galvanic currents. Gently increase the rheostat, from zero up 
to the point where it gives a good contraction in the normal muscle. To 
treat the affected muscles, take a slightly larger electrode and apply it to 
the motor point on the affected side. Start with the rheostat at zero, 
and advance it to not over two-thirds of the strength that was necessary 
to secure a response in the healthy muscle. Use a slow wave, only 
one or two to the second. Keep a careful daily record as to the number of 
waves given to the part being treated. Hot over three waves should be 
given the first day. Increase one daily until ten are being given at one 
treatment, after which drop to three and repeat another week. If, 
then, a test does not show improvement, keep repeating this schedule. 
When a marked improvement is shown, continue to increase one wave 
daily until twenty are reached, after which a series dropping back to 
ten and working up to twenty is instituted, until the muscle possesses 
marked signs of regeneration. At this point the rheostat may be advanced 
to the full amount which was necessary to produce vigorous contrac- 


FARADISM 


299 


tions in the healthy muscles, and, by degrees, the frequency of the wave 
may be increased, until three contractions per second are given. During 
the entire course of this treatment the muscle may gain from invisible 
response to a slight flicker of the tendon and, finally, to a full, deep 
contraction. After good contractions have first been elicited, occasional 
tests should be made with the faradic current, and, when the response 
with the faradic is good, the case may be treated, thereafter, entirely by 
faradic rather than by sinusoidal current. From this regime pass on to 
active motion and occupational therapy. 

The sinusoidal current is very useful as an aid in removing circulatory 
stasis through the mechanical effect of muscular contraction, following 
other physiotherapeutic measures, such as an application of heat, which 
will aid in preventing the organization of the exudate in a bruised 
muscle. As a local substitute for voluntary exercise, it has many ad¬ 
vantages. It is being increasingly employed in the stimulation of the 
finer intrinsic muscles in some of the organs of special sense. The 
gastro-intestinal tract may be both directly and indirectly stimulated by its 
use. One of the very last of the electrical currents to be perfected, 
it offers possibilities in the field of therapeutics that have as yet been but 
partly explored, and it is expected that the indications for its use will 
very rapidly widen in the near future. 


FARADISM 

Definition. —The faradic current is an induced alternating current, 
derived from a so-called induction coil. 

History. —This is one of the oldest of the fundamental types of elec¬ 
trical current. The principles of magnets and their relation to elec¬ 
tricity were first observed by Faraday in 1831. His subsequent work 
formed the basis for the introduction of the dynamo, the telephone and 
much of our modern lighting. 

Physics. —This current is characterized by relatively high voltage and 
low amperage and is alternating in character. A weak galvanic current, 
derived from a direct current main or from batteries, passes through a 
coil of wire surrounding an iron core which becomes magnetized. 

The induction coil is a very old and very well-known piece of 
electromedical apparatus and, although the coils produced by different 
makers are of somewhat different construction, the general principle is the 
same and the current differs very little in character or quality. We 
have a core made up of a bundle of fine wire, which is surrounded by a 
number of turns of a somewhat coarser wire. This is known as the 
primary coil. Opposite one end of this coil is a small piece of metal, 
fastened to a rather delicate metal spring. A small screw is mounted 


300 


ELECTROTHERAPY 


so that its point is nearly in contact with this spring, at about the 
middle of its length. One end of the primary coil is connected with 
one pole of the current supply and the other pole is attached to the screw. 
The coil and the spring are also connected. The current flows from 
the main or batteries to the coil, from this to the spring, jumping across 
to the screw, and so completing the circuit. The current passes through 
the coil with its wire core, making it temporarily a magnet which draws 
the small block of metal on the end of the spring toward it. In doing 
this it draws the spring away from the screw, breaking the circuit and 
stopping the flow of the current. When the current flow ceases, the coil 
loses its magnetism and the piece of metal flies back and the screw resumes 
its first position in relation to the spring. 

Physiological Effects. —The faradic current is the nearest approach 
to the normal motor nerve impulse that we are able, artificially, to obtain. 
The usual alternation rate of fifty per second probably closely approxi¬ 
mates the motor nerve stimulation rate. It acts through the nerves them¬ 
selves, the stimulation being carried into the muscle at the motor point and 
distributed to the individual fibers by the same mechanism that is con¬ 
cerned with their reception of the normal motor nerve impulse. For 
this reason, it is easily seen that, where the conductivity of the nerve 
is interfered with, there will be a corresponding interference with the 
transmission of faradic stimulation. This, it will be remembered, is 
contrary to the action of the interrupted galvanic current, which is able 
to secure a somewhat modified reaction of muscles by acting directly 
on them, without continuity of nerve structure. The type of faradic coil 
which gives the most rapid alternations secures the best motor response. 
Slower alternating currents produce an undue amount of sensory dis¬ 
turbance in proportion to the motor responses secured by them. Formerly, 
the faradic current was widely used for its undoubted effect in increasing 
metabolism in completely paralyzed muscle groups, where motor responses 
could not be elicited by its use. Sinusoidal, or some form of wave 
galvanism, is to be preferred for this purpose and the use of the faradic 
current reserved until the time when, as described in the section on 
sinusoidal currents, a fairly good contraction is obtained by its use. 
Where cutaneous stimulation is desired, a faradic brush is of value, but 
surface high frequency is more often used. 

A systemic result may be obtained where the neuromuscular system 
is normal, but the patient with a large amount of adipose tissue is 
handicapped. This may be burned up by the method of general muscular 
contractions induced by the faradic current, after the technic of Bergonie, 
described later in this chapter. 

Technic of Faradic Treatment. —The faradic current is adminis¬ 
tered, in general, in the same manner as the galvanic current. Moist 
electrodes are used, except in cases where a cutaneous stimulation is 


FAKADISM 


301 


especially desired. Then a small brush, consisting of a hunch of fine tinsel 
wire, is provided to serve as the active electrode. This is attached to 
one terminal of the machine and the brush moved back and forth lightly 
over the surface of the skin. There is, of course, not the danger of 
burning with this current that there is with constant current, on account 
of the frequency of alternations per second. However, extreme moisture 
of the electrodes is necessary to reduce the resistance of the dry skin 
and reduce the unpleasant tingling. 

The alternations so produced are not even or rhythmical in their 
periodicity. There are, of course, no polarity effects in the use of this 
current. There have been instruments designed to measure the faradic 
current, hut they are not as satisfactory as in the case of galvanic and 
high-frequency current, so that the sensation of the patient becomes 
the best guide that we have. In the usual type of apparatus, this current 
can be modified in its strength by a set relationship between the second¬ 
ary coil and the core. A rough measuring scale is marked on the machine. 

Major Bristow, of England, further modified a small portable ap¬ 
paratus, by providing for the manual insertion and withdrawal of the 
core into the machine, thus producing a faradic wave current, avoiding 
continual tetanization of muscle and perfecting an apparatus of great 
value for the purpose of muscle stimulation. 

Another modification for generalized muscular contraction, aimed 
especially at the reduction of adipose tissue, is that of Bergonie, of 
France, in which the current is applied to large muscle groups, by means 
of electrodes on a specially constructed chair with diversified control 
switches on the chair itself. 

Since the faradic current acts on the muscle through the nerve, 
the sharpest effect is produced by its application on the motor point of 
a given muscle. This point, as a rule, corresponds to the point of entrance 
of the motor nerve in the belly of the muscle. Therefore, it follows 
that the active electrode should be a small one, varying in diameter from 
one-half to one and one-half inches. 

Naturally, for the proper testing of the interossei and similar small 
muscles, the sharpest possible localization is desired, while for such 
muscles as the biceps a somewhat larger pad may be used. An indiffer¬ 
ent electrode should be four by six inches or even larger and both elec¬ 
trodes, chamois or felt covered, are prepared as for galvanism. Adequate 
moistening of them decreases the sensory effect. There is not the danger 
of destructive burns with faradism, which must be constantly watched, for 
instance, in the use of the galvanic current. The faradic current also 
may be interrupted by a metronome, by an interrupter handle on the 
active electrode or, better still, made wavelike by the core device de¬ 
scribed in the Bristow apparatus. The smoother and more even the cur¬ 
rent, the better the result. In any case, the current should be delivered 


302 


ELECTROTHERAPY 


to the muscle only in such quantity as will procure a good contraction and 
for the least possible space of time in which this desired result may be 
obtained. 

Normal physiological exercise of a muscle requires a contraction, dur¬ 
ing which the venous blood and lymph are squeezed out of the muscles and 
adjacent tissue. In the relaxation period, an increase of the arterial and 
capillary intake is made possible. When the application of an amount 
of current, sufficient to produce a good contraction, is maintained beyond 
that point of contraction, the muscle becomes tetanized and these natural 
changes in the circulation are interfered with. Skill in finding the 
exact motor point decreases the amount of current needed to obtain a 
good contraction. Therefore, the unpleasant effect of too strong a current 
upon the patient’s sensory nerve endings is lessened. It should never be 
necessary to use such an amount of current as will “splash through” to 
neighboring muscles, the stimulation of which may be unnecessary or 
even detrimental. A further point which should be emphasized is that 
the rest periods between contractions should be much longer, by four, 
or even eight, to one, than the period of the contractions. The British 
electrotherapists employ two-fifths contraction and three-fifths relaxation 
time. There is always the danger of giving too many stimulations to 
a weakened and regenerating muscle. Of course, the faradic current 
is not used until a muscle has regained a certain amount of power. 
From two to ten contractions, usually starting with the former and work¬ 
ing up toward the greater number, is sufficient, as a rule. Overstimula¬ 
tion is of real danger to the muscle. 

Example .—Stimulation of tibialis anticus. Make the patient com¬ 
fortable with a small support under the knee. With electrodes properly 
prepared, place the indifferent electrode, 'of four by six inches, under 
the calf of the leg, the leg resting upon it. Locate the motor point and, 
if necessary, mark it. Then, with the active electrode remaining in con¬ 
tact with the muscle at this point and with just sufficient current to 
produce a fair contraction, give from two to ten contractions according to 
the condition of the muscle at the time. 

Treatment of Obesity. —Edward C. Titus of New York has used a 
modification of Professor Bergonie’s technic for a number of years in 
the treatment of this condition. He uses a semireclining chair with lar^e 
metal plate electrodes for the back and adjustable extension for the legs. 
These electrodes are attached to the corresponding rheostat of the ma¬ 
chine and there are two electrodes for the abdomen, two for the legs 
and two for the anterior surface of the thighs. These electrodes are 
all covered with a moistened covering of the same thickness. They are 
bound on, those on the abdomen being held with sandbags. Good contact 
of the patient and chair electrodes is essential. 

Contractions are given very feebly at first, coming up to maximum in 



COMBINED CURRENTS 


303 


about ten minutes. These treatments are given in courses of six to ten 
weeks. Application should be daily for the first three weeks, then on 
alternate days, starting at twenty minutes and increasing to sixty. An 
average reduction of one-half to one pound per day may be expected 
and it has been the rule for improvement to continue after the treatment 
has been discontinued. 

These treatments consist in the muscles being contracted in a rhyth¬ 
mical manner, in which *the entire musculature of the body is concerned. 
In this way, a combustion within the muscles 
is greatly accelerated, but the signs of bodily 
fatigue which follow violent exercise are almost 
wholly lacking. Moreover, there are patients 
who, because of excessive weight or cardiac con¬ 
dition, could not take exercise which would in a 
marked degree aid in consuming their deposits 
of fat and their elimination of body wastes. 

For them this technic is ideal. 

The type of current is described as a coarse 
wire faradic. The interruptions of the current 
are made about thirty per second, or close to the 
normal rate of muscle fibrillation, and the mus¬ 
cular contractions are made to correspond as 
closely as possible to the heart rate. There is, 
in addition, a general building-up of the muscu¬ 
lature, replacing fat. 

With increased respirations and greater 
activity of the kidneys, active measures to re¬ 
move, as fast as possible, the cause of the 
obesity and to regulate the patient’s routine are, 
of course, essential. In many cases, where too 
rigid dieting causes marked weakness and 
where active exercise is impossible, this treatment should prove of value. 
Within a reasonable time after treatment is instituted, many patients, 
according to Titus, are willing and able to begin various types of active 
exercise. 



Fig. 7.—The Polysine Gen¬ 
erator Combining Many 
Types of Contractile 
Currents. 


COMBINED CURRENTS 

Several types of apparatus have been perfected, whereby a measurable 
proportion of galvanism and faradism may be combined in a single 
treatment. It is evident that such a current will be of advantage 
where a muscle is just beginning to respond feebly to faradism. Prac¬ 
tically, however, the sine or the interrupted galvanic may be used, until 
a sufficient response permits of our treating by the faradic current alone. 



•304 


ELECTROTHERAPY 


HIGH-FREQUENCY CURRENTS 

Diathermy 

Definition. —Diathermy, diathermia, transthermy or thermopenetra¬ 
tion is the bipolar application of the d’Arsonval type of high-frequency 
current, which develops a form of heat, sometimes called conversive, deep 
within the tissues. 

History. —In 1890, D’Arsonval demonstrated that the main effect of 
the high-frequency currents in the body was the production of heat. 

The following year he used cur¬ 
rents up to 3,000 milliamperes. 
That same year, Nicola Tesla 
proved that large currents of 
high potentiality, currents that 
could light up several incandes¬ 
cent lamps, might be used from 
Leyden jars without harm to the 
body. In 1896, D’Arsonval 
showed that he could produce 
heat effects in patients with cur¬ 
rents as low as 500 milliamperes 
and, in 1898, began to treat 
diseases with these currents. The 
first, use of the d’Arsonval cur- 

Delivering 2,500 Milliamperes of Cub- rent m therapeutics was made in 
rent. this country by Frederick De- 

Kraft, in < 1906, in the office of 
William Benham Snow, of New York. In 1907, Nagelschmidt designed 
the first real diathermy apparatus and gave the name diathermy to this 
form of treatment. Tesla had suggested the use of high-frequency cur¬ 
rents in medicine as far back as 1891. We are indebted to Bordier, 
Lecomte, Bouiniot, Wertheim, Aimmern and others, for early experimen¬ 
tation with this current. In 1908, von Verndt, von Preiss and von Zeyneck 
urged the use of the d’Arsonval current in the treatment of joint diseases. 
Diathermy was first used in England, in St. Bartholomew’s Hospital, in 
1909. In 1910, Nagelschmidt used diathermy in hospital practice, but 
with a type of apparatus that did not give the properly sustained oscilla¬ 
tions. Erom 1910 on, a number of new types of apparatus were devel¬ 
oped, both in this country and abroad, until we now have several makes 
of high-frequency machines, combining not only a d’Arsonval current -of 
good quality, but Tesla and Oudin currents as well. 






HIGH-FREQUENCY CURRENTS 


305 


Physics. The current used in diathermy is the bipolar d’Arsonval 
current, which has a high voltage and relatively high amperage. The 
frequency of oscillation must he great enough not to tetanize the muscles; 
that is, over 10,000 alternations per second. Tc produce the desired 
type of current some device must be used to “step-up” both the voltage 
and the frequency of the current coming from the main. Major C. M. 
Sampson has clearly illustrated the effect of high-frequency current, by 
comparing it to water power, somewhat as follows: A stream of water, 
six inches in diameter, having a pressure of a thousand pounds per square 
inch, would he difficult to control and dangerous to life if it struck the 
body hut, if passed through a great nebulizing apparatus, which reduced 
it to a fine mist, it would float and rise in the air, whatever the pressure 
behind it. Such a spray would correspond to our high-frequency current 
and could he applied to a patient with no ill effects. 

The standard d’Arsonval type of high-frequency machine is further 
described as follows: It contains, first, a control mechanism, either a 
rheostat choke coil or autotransformer, to govern the amount of current 
drawn from the main. Secondly, a “step-up” transformer, usually oil 
immersed, which takes the low voltage current and steps it up to the 
desired voltage, somewhere between ten thousand and thirty thousand volts, 
the amperage decreasing in direct proportion. This first transformer does 
not affect the frequency of the current, but only the voltage and amperage 
which is still dangerously high. Tap-offs or leads are taken from the 
secondary on this transformer and connected to the primary of a second 
step-up transformer, which may he of the Tesla type, usually wax im¬ 
mersed, or a d’Arsonval solenoid. 

Between the first and second transformers are placed two devices, a 
condenser and a spark gap. The function of the condenser is to store 
the current and to step-up the frequency. The condenser usually employed 
in the diathermy apparatus consists of a number of metal plates, separated 
from each other by some insulating material, such as mica or glass, and 
has a larger capacity than Leyden jars used in other types. This greater 
capacity produces oscillations which are more sustained. The condenser 
is placed in the secondary circuit. The current may then pass into the 
condenser or around the metallic secondary circuit in which the resistance 
is low. 

In order to make the current enter the condenser, the spark gap, which 
is another resistance of variable amount, is placed in the circuit. ISTow, 
the current meeting this new resistance tends to travel the reverse side of 
the circuit into the condenser and the condenser is charged with it, the 
first plate being charged positively and the second negatively by induction 
and so on. When charged to capacity, the current is discharged en masse 
across the spark gap completing the high-frequency circuit. 

The circuit leading from the first to the second transformer must he 


30G 


ELECTKOTHEBAPY 


tuned to resonance, which is done by equalizing the inductance resistance 
to the capacity of the condenser. Here, the function of the condenser is 
to store up sufficient power to excite resonance in the circuit. 

When the spark gap is closed or offers insufficient resistance to the 
current, the condensers are not charged and there is not enough energy 
to set up vibration in the resonators. Care of the spark gap, therefore, 
is absolutely essential to the proper working of the machine. 

The Spark Gap and Its Proper Care. —The care of the spark gap is 
perhaps the most important thing the physician has to know in the 
care of his machine. A dirty and corroded spark gap 
will interfere with the smoothness and evenness of 
the current to such an extent as to nullify the good 
that might be accomplished by the treatment. Where 
the DeKraft spark gap is used the micas must often 
be cleaned, rearranged and turned so as to present 
clean fresh edges. Alcohol is the best substance to 
clean both the metal and the mica. Where the 
hooded target spark gap is used, this too must be 
cleaned and the end of the rod constantly freshened 
and kept level to insure an even current. The use 
of cork or ground glass for better insulation, and of 
finer degrees of adjustment in some of the latest 
types of spark gap, will greatly reduce the amount of 
care required. 

In some smaller types of machine, loose contact 
may occur between the metal regulator and the but¬ 
tons on the rheostat, when they become slightly loose by wear. This may 
be prevented by inserting a chip of Crook’s metal. Some types of machine 
require grounding and, in this case, one must be sure the ground wire is 
in place. 

The Milliamperemeter and Its Significance. —In the ordinary type of 
machine there is placed in circuit a hot wire milliamperemeter. This 
meter only gives a roughly approximate idea of the amount of thermal 
effect the patient is getting. As Mr. H. E. Dorsey has pointed out, it 
measures only the total amount of the current delivered to the patient 
and takes no account of varying resistance within or without the body. For 
instance, if the part treated has a low resistance a strong current will be 
indicated by the meter, without a large rise in internal temperature. 
But, if the resistance of the part is high, for example, through the knee, 
a smaller current will produce a more intense degree of heat. Hence 
the meter records the total amount of current passing, while the degree of 
heat produced depends upon the current density and the resistance of 
the tissue. With size of electrodes and density of tissue the same, the 
heat produced varies as the square of the current strength. Thus a 



Fig. 9.—A Standard 
Type of High-fre¬ 
quency Apparatus. 


HIGH-FREQUENCY CURRENTS 


307 


relatively small increase in current strength will greatly raise the internal 
temperature. The reading then will vary according to the type of machine, 
the part treated and other variations in technic in each case, and is only 
fairly constant for the same machine used in the same way. 

Physiological Effects. —Diathermy is applied to the body by the 
bipolar method and heat is generated in the tissues in proportion to the 
square of the amperage used and the resistance to the passage of the 
current. It must be clear that this is an entirely different form of heat 
from any heretofore used in medicine, and in its effect totally different 
from that resulting from the application of any form of heat conducted to 
the skin through the air or applied directly to it. This high-frequency 
current, because of its high voltage, is able to take a direct path through 
the tissues and is not greatly affected by their relative resistance. It 
takes the direct rather than the easiest path, one might say. 

We have spoken of the general construction of the d’Arson val ap¬ 
paratus and the manner in which this current is generated. Before con¬ 
sidering its specific local and systemic effects, it would be well to have 
in mind some of the qualities possessed by this type of current. A 
current oscillating at this extremely rapid rate of approximately a million 
per second is too rapid to institute ionic movement. There is, therefore, 
no muscle contraction, no ionizing effect, but only sedation and the 
development of heat. 

Local Effects. —There is produced a very mild hyperemia of the skin, 
increased activity of the skin glands beneath the electrodes and lessened 
skin sensitivity. Increased cellular activity of any given gland in the 
pathway of the current is produced, with no tetanization of muscle, with a 
proper technic. The sedative effect upon nerve endings has been demon¬ 
strated by decreased pain and diminished electromotor responses. Active 
arteriole and capillary dilatation follows. This increases the local arterial 
blood supply, increases the amount of lymph passing into the tissues and 
quickens the venous return by lowering the capillary resistance to the 
blood-stream. Nearly all these effects are directly proportional to the 
amount of heat produced, and this depends again upon the size and type 
of the electrodes used, the amount of the current and the length of the 
treatment. Heating is intensified during the latter part of the treatment. 

General Effects. —The distribution of the heat by the body fluids 
raises body temperature somewhat from .5° to 2.5° F. There is a lowering 
of blood-pressure, with mild general stimulation of the processes of 
metabolism and especially of elimination. With heavy currents there 
may be a general feeling of lassitude and sometimes fatigue, especially 
in elderly persons. A quickening of the pulse rate is often noted and a 
general increased activity of the eliminative mechanism. 

Experiments. —If the autocondensation handles are held in either 
hand, when the current is turned on, the wrist becomes warm; with a 


308 


ELECTROTHERAPY 

• 

stronger current, the arms and shoulders become hot and the wrists very 
hot and cramped. 

1. Uumberbatch noted the following temperatures in a patient using 
this technic with 400 milliamperes for 20 minutes. There was a rise of 
temperature, Fahrenheit, as follows: front of the wrists, 6°; front of the 
elbow, 4°; axilla, 2.4°; mouth, 2.6°; groin, 1.2°, and popliteal space, 
3°. The rise of temperature in the mouth and in distant parts was due 
to the heating of the blood-stream, and the maximum temperature was 
in the wrist where the current density was greatest. 

2. In a second experiment the same technic was used with 500 
milliamperes to maximum tolerance, which gave a temperature in the 
front of the wrist of 20°. The flexor side of the arm was 3° to 4° 
warmer than the extension side, which increased to 6° when the arms were 
flexed. With the electrodes over the chest and abdomen, no rise of body 
temperature was secured. 

3. D’Arsonval demonstrated that all parts of a saline solution were 
equally heated. He further showed that, in passing diathermy along the 
hind legs of a rabbit, the deeper tissues, as well as the skin, could be 
coagulated by strong currents. 

4. Maragliano passed diathermy through the thorax of a dog in 
which a small electrical lamp had been placed. The lamp became 
incandescent. 

5. A series of experiments with liver illustrated the conductivity 
of saline solution to the diathermy current. Strips of liver were cut 
6 by 1 by 1 inches. In each case 450 milliamperes were used for four 
minutes. ( a ) Crook’s metal electrodes, 4 inches long and 1 inch wide, 
were wrapped around both ends, the liver placed in a dry dish and the 
current turned on. The liver was thoroughly cooked through and was 
especially well done in the center, (b) Both liver and electrodes were 
placed in the salt solution and the cooking was very much less marked, 
(c) One end was raised as before, the other end placed on the elec¬ 
trode on the bottom of the dish. The liver was cooked except on and under 
the electrodes. ( d ) The free electrode was simply placed over the edge 
of the dish down into the saline and the results were the same as 
in C, but the cooking not quite so thorough. These experiments indicate 
that the direct application of plates is more efficient than through the 
water, but that a true diathermy may be obtained through saline into which 
an electrode has been placed. 

6. Cumberbatch describes a case in which the palms were moistened 
with saline and the thermometer placed between them. The elecftrodes 
were applied to the back of the hands. One thousand four hundred milli¬ 
amperes for six minutes gave a 7° E. rise of temperature. It is to be 
noted here that we have two extra layers of skin with their added re¬ 
sistance and the rise of temperature is, therefore, greater than it would 


HIGH-FEEQUEHCY CUEEENTS 309 

be in the middle with the same mass of tissue, as, for instance, in the 
forearm. 

7. In a large growth on the hack of the neck, with the indifferent 
electrode on the chest, an active circular electrode, three-fourths of an 
inch in diameter, was placed on the growth. A thermometer was thrust 
into the growth one inch below the active electrode. The temperature 
rose to 110° F. 

8. Illustrating edge effect. When two electrodes are placed side by 
side or end to end, the hottest point is between them. Two electrodes 
were placed on the back of the forearm, the nearest edges one inch 
apart. The temperature of the skin under the center of the plates rose 
8° F., on the edge facing the opposite electrodes, 21° F. 

9. Saberton experimented with a dish of egg-albumin. Two elec¬ 
trodes were placed in the albumin at opposite sides. When a heavy 
current was turned on suddenly, the coagulation first appeared immedi¬ 
ately beneath the electrodes. When turned on slowly coagulation took 
place first in the center. 

10. Flexible metal electrodes were bound on the opposite sides of a 
large potato. Fifteen minutes of moderately strong current were ap¬ 
plied. The potato was cooked in a diamond shaped area, broadest in 
the center. 

11. The temperature of the brain can be raised by diathermy through 
the skull. Gloetta and Waser 1 showed 1° C. rise in the lateral ventricle 
of a dog after diathermy for ten minutes. 

From our clinical experience with this current and from the fore¬ 
going experiments, we may conclude: 

1. That diathermy does develop a deep-seated and real heat within 
the tissues. 

2. While this heat is great enough to coagulate protein, there is no 
danger in its application to normally vascularized tissue, because the 
circulation of the body fluids diffuses the heat. 

The amount of heat developed depends upon the resistance of the 
tissues and the current density. With a given milliamperage, the current 
density is equal, if the electrodes are of the same size and the greatest 
amount of heat is obtained halfway between them, when the current 
is slowly turned on. If electrodes of unequal size are used, the current 
density is greater a short distance below the smaller electrode. Thus 
we are able to localize the desired effect. In the application of diathermy 
to the fingers or toes, advantage may be taken of its condition through salt 
solution. 

The Machine. —To give satisfactory diathermy treatments, an ap¬ 
paratus must be capable of delivering at least 2,000 milliamperes of cur- 


J Arch. f. Exper. Path. u. Pharmak., June 25, 1914. 



310 


ELECTROTHERAPY 


rent. Fortunately, there are several types easily portable which are of 
sufficient power. The larger machines for office practice are most 
economical when built exclusive of many seldom used attachments. No 
true sinusoidal current can be.derived from a high-frequency outfit in spite 
of advertisements to that effect. 

When the apparatus will not work, first see that every switch is 
closed and the wall plug fully inserted. Next, test the circuit outlet with 
a lamp or other piece of apparatus. If the trouble lies elsewhere examine 
next the spark gap, taking it apart, cleaning and rearranging it, if it is 
of the DeKraft type, or using emery cloth on the double button variety. 
Further taking down of the machine is inadvisable, except in expert 
hands. Most manufacturers are providing good repair service where 
possible. 

Electrodes. —Many types of electrodes are now on the market. 
Crook’s or composition metal, twenty-two gage, are perhaps the best for 
general use. These may be cut into convenient sizes and shapes. All 
four edges should be turned sharply back and rolled flat. A slightly 
longer flap left on one end will facilitate the attachment of the clip. 
Several electrodes should be prepared to fit easily over curved surfaces, 
such as the point of the shoulder. This is done by slitting the side or end 
so that overlapping is possible. Lighter weight metal is sometimes 
used. Tinfoil is very convenient for use on the phalangeal joints with 
small amounts of current. I prefer varieties of twenty-two gage metal 
for general use. 

The solid steel disc type with handle is inflexible, requires holding in 
place and can only be used on flat surfaces. A new type of electrode, 
consisting of wire mesh over soft material supported by a solid metal 
back and applied by means of a retaining handle, has just been brought 
out. With this handle a pair of electrodes may be quickly applied to 
the opposite sides of ankle or knee and will remain firmly in place. 
German silver mesh may now be purchased in required amounts and quite 
durable pads made with it. In some modifications of diathermy the 
autocondensation pad, vacuum or non-vacuum high-frequency electrode 
or hand of the operator or patient are connected to one d’Arsonval 
terminal and act as an electrode. 

General Technic. —The patient must be made comfortable, the part 
to be treated well supported, and he should, if possible, be “mentally 
prepared,” as before suggested. The machine should be examined to 
make sure the spark gap is closed and the rheostat on “I.” Close the 
knife switch to make sure the machine is running. It is well to warm 
the composition metal plates by placing them face upward under the 
radiant light or in very hot water. With shaving brush and soap, 
prepare a heavy, hot soap lather and, applying it freely over the elec¬ 
trodes, place them on the skin. Attach the metal cord tips with clips 


HIGH-FREQUENCY CURRENTS 


311 


or simply place them on the back of the electrodes and bind them firmly 
with elastic or cotton webbing or rubber bandage. 

Inspect again the attachments of both cords and then close the 
machine switch. In the average treatment, from three to five minutes 
should he taken to raise the current to maximum, and two or three minutes 
used in reducing it. This may be done by the following method when 
using the DeKraft gap: Open the spark gap slowly one or two notches. 
It may then be closed one notch and the rheostat switch placed on the 
second button, when it is again slowly opened. After a moment, this 
procedure is repeated, until the third, fourth or fifth button on the 
rheostat, as desired, is reached and the spark gap on the second, third 
or fourth notch gives the desired maximum current. This procedure 
should take not less than four minutes for its completion. 

With the hooded tungsten or turn-screw type of gap, it is often 
possible to place the rheostat at the desired position for maximum 
treatment and to depend on the very gradual opening of the spark gap 
above, to gradually increase the current strength. 

It is desirable to take about one-half as much time in reducing the 
current as was consumed in raising it to maximum. Neglect in the 
use of the requisite time for both of these measures may result in painful 
and generally unpleasant sensations on the part of the patient. 

Where it is desired to localize the heat near one surface, select 
electrodes of unequal size. The current density and heat production 
is greatest beneath the smaller electrode. When plates of the same size are 
used the heat is generated in the center of the tissue mass between them. 
Less current is always required in dense tissue, such as the knee-joint, 
than through less dense tissue, such as the abdomen. It should be re¬ 
membered that, since the heat varies as the square of the current in 
any given tissue density, a slight increase in the milliampere needle read¬ 
ing will give a marked rise in the internal heat produced. This is the 
reason why some patients are sensitive to what seems to he but a slight 
increase of the current. 

In normal tissue with good contact, it is safe to use 100 milliamperes 
of current for each square inch of the smaller electrode. In very 
vascular tissue, and where the resistance is especially low> this allowance 
may be increased 50 per cent. The patient’s sensation is a reasonably 
good guide. When, however, one is treating anesthetic areas, extra 
precaution regarding both the contact and the current strength must 
be taken. Patients having arteriosclerosis must he treated with extreme 
caution. Their vascular elasticity is impaired and their heat diffusion 
sluggish. A dusky red erythema under the electrodes is a warning 
that the current strength must he reduced in subsequent treatments. When 
a pair of plates are used on opposite sides of a limb or other similar 
situations, it is of the utmost importance to see that they are equidistant 


312 


ELECTROTHERAPY 


at all points. When this is not done, an undue current density is 
developed between the near points which may cause a burn. Such a 
situation may arise, for instance, in the knee, by the patient changing 
his position after the plates are properly placed. 

The patient is unaware of the degree of sensation the treatment 
should produce. Hence, he should be instructed to inform the operator 
at once of any particular points of heat or faradic sensation. When 
these unpleasant sensations occur, turn the current slowly off, reinsert 
soap lather with brush or finger, press the electrode down firmly at that 
point, reapply the bandage, and slowly increase the current again. 

When the current has been cut off completely by slowly reducing the 
current, remove the electrodes and carefully dry the skin. There is no 
danger in the patient going outdoors with reasonable protection, by the 
time he is dressed and ready to leave the office. 

Special Technic — Knee .—Lateral plates, while parallel, should be 
placed slightly nearer the front than the back of the joint, due to the 
sensitivity of the skin in the popliteal space. Some operators “cross 
fire” the joint by using first anteroposterior and then lateral plates. 

Another method of reaching the joint surfaces is to flex the joint 
fully, placing one plate below and one above the patella. 

Heart and Lungs .—Use fairly large plates, perhaps five by seven 
inches, and turn the current on and off with great care. A steady current, 
as shown by a stationary needle on the milliamperemeter, must be used. 
It is unnecessary to bind the plates on, as the patient may lie on the 
posterior one while the other is held gently but firmly on the chest. 

Brain .—Diathermy of the brain has been successfully used in a 
number of conditions. The electrodes may be applied to forehead and 
occiput or, laterally, through the parietal region. It is necessary to 
employ a current of absolute steadiness. One taken from a machine 
where there is the slightest to and fro movement of the meter needle 
is unsuitable. Not more than 500 milliamperes should be used for a 
maximum of fifteen minutes. Extra care and time must be taken in 
increasing and decreasing the current strength. 

Spine .—It has been a common custom to apply two long, narrow 
electrodes to either side of the spine. I do not believe that any thermal 
effect on the spinal cord or vertebral articulations, and but slight effect 
upon the erector-spinse muscles, can be obtained by this method, because 
of the edge effect. The major portion of the current passes along through 
the skin and the subcutaneous tissue between the near edges of the 
electrodes. It is our custom to treat such cases by having the patient 
lie prone upon the autocondensation pad, using a movable, non-vacuum, 
surface electrode over the spine. 

If more convenient, one long narrow electrode over the spine mav 
be substituted for the movable electrodes. We thus localize the heat 


HIGH-FREQUENCY CURRENTS 


313 


constantly under the electrode, obtaining the greatest current density 
in the structures beneath it. 

Extremities. —A direct current may be used by applying two vacuum 
or non-vacuum electrodes to opposite sides of the elbow or hand, for 
instance, keeping them constantly in motion. This might be termed 
a movable, direct technic and is useful in the elbow, on the fingers, hands 
and feet. The hands and feet can also be treated through saline solution. 
In treating one of the proximal joints of the fingers, one metal plate is 
bound around the midforearm, the other placed in the bottom of a 
non-conducting vessel filled with saline and the fingers immersed in the 
solution. Then the current is turned on and a strength of 500 to 600 
milliamperes used. After the other fingers are withdrawn one at a 
time, the patient feels the increased density of heat in the affected finger 
which is greatest when all the other fingers are raised. If the heat 
then becomes too great, a second finger is replaced in the saline. This 
technic has the advantage of being entirely under the patient’s control 
and he soon learns to regulate the amount of heat he is able to endure 
in the affected finger. If it is desired to treat the wrist, the whole hand 
may be placed flat on the bottom of the retainer. The foot is treated 
in a similar fashion. For the treatment of the hand and wrist, if the 
fingers are flexible, we use a technic similar to the above, except that 
the patient holds the autocondensation handle in the hand instead of 
immersing it in the saline. 

Another technic in general use is the zone or cuff method for 
treatment of the extremities. For instance, in treating the elbow one 
electrode encircles the upper arm, the other the forearm. It is believed 
that most of the current is passed along the muscles, tendons and sub¬ 
cutaneous tissue and that comparatively little is obtained in the joint 
itself. It is true that this skin or zone effect is diminished if the elec¬ 
trodes are widely separated or heavier currents used, but, if it is the 
elbow or the knee that is affected, the through and through technic 
first described seems more efficient. For the sharp localization of heat, 
close to the surface, as, for instance, in the gums following dental 
trauma, or over the temperomaxillary region, Eleanor Volkmar of Wash¬ 
ington has suggested placing the patient on the autocondensation cushion. 
The operator, holding an electrode in one hand, makes quick contact 
with the whole hand, then, using the fingers as rheostats, concentrates 
the heat beneath the tip of one finger. We have modified this method, 
by placing the operator seated on another autocondensation pad, giving 
more freedom in the application of the treatment. A knowledge of the 
physics involved and the therapeutic problem at hand will enable one to 
still further modify the technic along rational lines. 

Autocondensation. —This technic of general diathermy is in common 
use. The patient is seated or lies prone—the latter preferred—on the 


314 


ELECTROTHERAPY 


autocondensation mattress or pad. This cushion is attached to one 
d’Arsonval terminal and the steel cylinder electrode, attached to the other 
terminal, is held firmly in both hands. From 600 to 800 milliamperes are 
given for twelve to thirty minutes. 



Fig. 10.—Atjtocondensation for Hypertension. 


Precautions. —There may be improper contact between electrode and 
skin. 

The current concentration may be too great, as when there is a near 
approach of two plates at some point. 

Because of local anesthesia the patient may be unaware of a degree 
of heat approaching pain. 

The tissue vascularity or vasomotor mechanism may be subnormal 
as in scars and arteriosclerosis. 

Contra-indications. —These are very few in number and include: 

Inflammatory conditions associated with walled-in pus. 

Conditions where there is danger of instituting hemorrhage, such as pul¬ 
monary tuberculosis with cavity formation and gastric or duodenal ulcers. 

Phlebitis, usually classed as a contra-indication, has been distinctly 
helped by diathermy in several recent cases with no untoward results. 

SURGICAL DIATHERMY 

Definition. —-'Surgical diathermy is the destruction of tissues by raising 
and localizing heat within them to the point of coagulation or desiccation. 
It has also been termed diathermic cauterization, but differs from other 




SURGICAL DIATHERMY 


315 


types of cauterization in that the heat is generated in the tissues instead 
of being conveyed to them by conduction. It differs also from chemical 
galvanic cauterization, which is caused by the concentration of caustic 
ions at the poles. 

The chief advantages of surgical diathermy over other operative pro¬ 
cedures are: 

1. Certain tumors, otherwise inoperable, may be removed. 

2. This procedure is practically without hemorrhage, making it of 
special value in conditions such as cancer of the tongue. 

3. Danger of spreading metastases is much less than with the use 
of the knife, because the blood-vessels and lymphatics are sealed in the 
procedure. 

4. The field of operation is sterilized by the heat developed. 

5. Surgical shock is in many cases less. 

6. The operation is rapid and often not difficult. 

7. Postoperative adhesions are seldom formed. 

Among the chief disadvantages of this procedure may be mentioned: 

1. The operator cannot bare important structures, such as nerves, 
arteries and veins as he does in blunt dissection. 

2. Normal tissue is destroyed along with the malignant tissue in the 
same area. 

3. The danger of causing hemorrhage, when performing surgical 
diathermy near large vessels, is obvious. 

4. The liability to form keloids, in operations where large areas of 
skin are involved, is great. 

5. The tissues must be easily accessible. 

6. Patients who are extremely weak do not stand this procedure 
well. 

Technic. —We are largely indebted to William L. Clark, of Phila¬ 
delphia, for the development of the technic of desiccation. A general 
anesthetic is usually required. The indifferent electrode, usually a large 
flexible composition metal plate, is well lathered and applied with the 
same care as in medical diathermy. One must be sure, in a prolonged 
operation, to keep plenty of soap under this electrode. After the opera¬ 
tion is completed the patient’s skin is dried and powdered. The active 
electrode consists of an insulated handle with metal center to which 
needles, or a group of short needles, knives, buttons and various other 
attachments can be fastened. 

When the apparatus and electrodes are in readiness, the current is 
turned on and the knife or button is pressed firmly into the tissue to 


316 


ELECTROTHERAPY 


be destroyed. From 1,000 to 2,000 milliamperes of current are used. 
At first, bubbles of steam and gas are given off and, in the very short 
time it takes the tissue to coagulate, usually a few seconds, sparks will 
jump from the electrode to the surrounding tissues, at which point the 
current should be instantly turned off. Intense contraction of muscles 
and undue stimulation of surrounding nerves occur, if the treatment is 
prolonged. When the current is turned off after the appearance of the 
bubbles, the tissue is coagulated. The tissues are coagulated to a depth 
roughly equal to the diameter of the electrode and in cross-section about 
half its diameter beyond the edge of the electrode. When the needles 
are used, the depth of coagulation is much greater, but not as great in the 
cross-section. The less vascular the tissue, the more quickly will the 
coagulation occur. When large masses are to be coagulated, it is neces¬ 
sary to prevent too sudden drying by dropping salt solution constantly 
along the electrodes. 

It is believed that this procedure is of sufficient value to justify the 
addition of this apparatus to the equipment of every modern operating 
room. 


UNIPOLAR HIGH-FREQUENCY CURRENTS 

Tesla and Oudin Currents. —One of these two types of simple mono- 
polar high-frequency currents is generally combined with diathermy in 
a single apparatus. The general physics of the current is somewhat the 
same. The Tesla transformer consists of a secondary coil wound around 
the solenoid for the purpose of raising the tension of the current. The 
Oudin resonator is made of a coil wound vertically on a solid base. Coils 
on the resonator, acting as the primary high-frequency solenoid, and 
the remaining coil by resonance, thus arranged greatly increase the volt¬ 
age. Condensers in these types of current may be of the plate type 
described under diathermy, or Leyden jars. The former has been 
described. 

Leyden jars are containers nearly filled with, saline. They are 
made of glass, lined inside and out with metal which becomes the arma¬ 
tures, the glass acting as the dielectric. The inner side is connected to 
a rod or chain, the outer grounded. The inner coat is charged by the 
high-tension coil, producing a charge of the opposite sine in the outer 
coat. A metal conductor from the outer coat near the rod to the inner 
coat forms a spark gap and discharges the jar. In the common Oudin 
resonator, the voltage of the current can be raised sufficiently to produce 
a strong violet brush discharge, in glass vacuum or non-vacuum con¬ 
denser electrodes. 

Vacuum Electrodes. —Vacuum electrodes are known as condenser 
electrodes. The current carried to them by a cable charges the vacuum 


UNIPOLAR HIGH-FREQUENCY CURRENTS 


317 



and innei suiface of the electrode and a corresponding charge is induced 
in the outer surface of the glass. The current induces a violet-colored 
fluorescence within the vacuum. When brought in close contact with 
the skin the electrodes give a brush discharge of slightly warm and 
stinging character. If they are kept in contact with the skin and moved 
rapidly, the skin becomes warm and hyperemic. Vacuum electrodes 
of thin glass, of various sizes and shapes for surface and cavity work, 
and shaped to a common insulated handle, are supplied by the manu¬ 
facturers of the various machines. These electrodes tend graduallv to 
lose their vacuum and to become less and less efficient, but are fairly 


Fig. 11. —The Application of Surface High-frequency. 

inexpensive to replenish. They have been known to explode and break 
in fine particles during treatments. 

Edward C. Titus, of New York, has been doing some valuable work 
with electrodes filled with helium gas. This work seems to indicate 
that an electrode of high efficiency and durability may in time be pro¬ 
duced in quantity, and form a valuable addition to our apparatus. 

A non-vacuum, silver-lined and insulated handle electrode has been 
produced of a much higher efficiency than the common vacuum type. 
This product is on the market in every form and variety. It is still 
slightly short of structural perfection, tending to oxidize after a certain 
amount of use. But, all things considered, I believe it to be the most 
efficient electrode now at hand. 

Physiological Effects. —Locally, a counterirritant effect upon the skin 
is produced, which is greatest at the edges of The moving surface elec¬ 
trode and increased by the widening of the spark gap. Heat is produced 




318 


ELECTROTHERAPY 


in the tissues immediately beneath the electrode and to a variable depth, 
depending upon the strength of the current. This combined effect 
stimulates greatly skin-cell metabolism and the activity of the skin glands. 
The general effect is due to the fact that the body is completely charged 
and discharged with each oscillation of the current, as proved by a 
spark jump to a second person, if near contact is made. This effect 
is similar to, but slighter in amount than, the systemic effect of diathermy; 
that is, there is a very slight warming of the body, a relaxation of ten¬ 
sion and a general stimulation to all cell metabolism. It is not, as a 
rule, used for this general effect but only in local heat production, the 
stimulation of the*skin and closely underlying tissue being the usual 
indication for its use. The two types of current differ but little in 
their effects. 

Technic.— The spark gap and rheostat are started at zero. See that 
all connections are tight, the electrode firmly attached, the skin dry 
and powdered. In nervous patients apply the electrode before opening 
the spark gap one notch. In addition, the first time the patient is treated 
it is well to let him first try the current on the palm of the hand, before 
applying it elsewhere. The reason for using powder is to take up the 
amount of perspiration developed and to enable the electrode to slide easily 
over the skin. Most cables, when new, can be held to the handle of the 
electrode in the grasp of the operator. When the insulation is worn, as 
often is the case, they should be held free from the patient’s body and 
close to the handle of the electrode by a loop of bandage, handkerchief 
or towel. 

It is annoying to the patient to have the cable brushing the skin, 
but, even though the insulation is poor, he will receive no spark from 
the cable while the electrode is in contact with his skin. When the 
electrode is being applied or removed, he may receive a hot spark from 
some part of the cable touching the skin, producing a burn. The elec¬ 
trodes should be cleaned with warm water after each treatment, being 
careful in the non-vacuum type not to get water into the electrode through 
the opening for the metal loop on top. With the skin powdered and the 
electrode in place, the spark gap and rheostat are gradually increased 
to the desired strength of the current. 

In general, this current is useful in producing hyperemia through 
its thermal effect in the neck, the joints of the hand and foot and other 
superficial tissues, where diathermy electrodes are difficult to apply. It 
is useful, as stated, for stimulation of the skin glands and, to a slight 
degree, for general stimulation along the spine. In the latter case a 
wide spark gap and low rheostat is used. If the current is on before 
the electrode is applied to the skin, it should be applied very quickly, 
kept in fairly rapid motion, the excursions of which must be great enough 
continually to cover an entire new surface of skin, otherwise some of 


STATIC ELECTRICITY 


319 


the electrode is in constant contact with, the same area of the skin, result¬ 
ing in overstimulation. The electrode may he removed quickly with the 
full current on. It is not necessary, as is the case with diathermv, 
gradually to work the current down before discontinuing the treatment. 

The subject of high frequency should not he dismissed without a 
word regarding the small toy machines with which the country is flooded. 
Efficacy in the treatment of almost every ill the flesh is heir to is claimed 
for them. If potent as claimed they would be dangerous in the hands 
of the laity. There can be no question that they share the danger of other 
similar procedures: that of delay in proper diagnosis and treatment of 
conditions, where such delay may be serious or fatal to the patient. This 
cheap type of apparatus has only a low frequency of oscillation, no 
resonance or quality of current. The current it produces resembles the 
rich smooth powerful current of a well-made machine in the same way 
that the tone of one cheap fiddle resembles the combined strings of 
the symphony orchestra. It is a safe rule in electrotherapeutic prac¬ 
tice, as elsewhere, that the best work can only he done with the best tools. 

STATIC ELECTRICITY 

Definition. —Static is a form of electricity of extremely high voltage 
and low amperage. It is developed by friction, is hard to insulate and 
has distinct polarity. 

Uses. —Static was classified under the mechanical currents. By means 
of it we are able to produce mild and superficial or deep and powerful 
contractions of muscle tissue, which is to some extent shared in by other 
types of cells, so that it has been at times called cellular massage. By 
means of no other currents or combinations of currents, nor by the use 
of any other type of physiotherapy can like effects be produced to the 
same degree. In routine office practice there are a number of disadvan¬ 
tages in the use of this current; among them are: 

1. The expense of a well-made and sturdy type of machine. 

2. The amount of room essential to its proper use. 

3. The awe and dread which the size and power of the apparatus 
provokes in the uninstructed, in this really most safe of all currents. 

4. The exploitation of the undoubted psychological effect of this cur¬ 
rent by those who do not understand it or its legitimate uses. 

History. —We are indebted to the late William J. Morton, who first 
used static about 1880, and more recently to William Benham Snow, 
Frederick DeKraft and Major Chris M. Sampson, of this country, and 
W. J. Turrell, of England, for the further introduction and standardiza¬ 
tion of static electricity in therapeutic practice. 


320 


ELECTROTHERAPY 


Apparatus. —The two principal types of static machines built in this 
country are, in the opinion even of foreign workers, superior to any made 
abroad. They consist of two separate compartments, in the smaller of 
which two revolving glass charger plates with brass brush collectors are 
placed, turned either by hand or motor. In the larger section are a 
series of glass or fiber plates arranged in pairs and revolved practically 
always by motor power. The size, number of pairs and possible speed 
of the plates, all are determining factors in the efficiency of the apparatus. 

The type of machine having been chosen, the next thing to consider 
is its location. The static machine should be placed, if possible, in a 
room by itself and, in any event, at as great a distance as possible from 
the walls and other apparatus. A point emphasized by Sampson is the 
proper grounding of the machine. He stated that a ground wire should 
be suspended at least three feet above and one or two feet in front of 
the machine and should not come nearer than this distance to it. In 
this way leakage is reduced to minimum. Connection from the ground 
to the machine may be made by using a piece of heavy copper wire three 
or four feet long with a flexible chain and hook at the lower end for 
attachment to the proper pole of the apparatus. It must be so arranged 
as not to swing close to the other pole of the machine or to the patient 
on the platform. The other end of the ground wire may be connected 
to a radiator or water pipe or to a copper rod driven into the ground. 
Both the end of the wire and the object around which it is twisted should 
be freshened with emery cloth and the connection made tight by several 
turns or by soldering. Loose connections quickly oxidize, offering in¬ 
creased resistance to the grounding of the current and interfering with 
the efficiency of the apparatus. The ground wire should never be attached 
to the frame of the machine nor laid on the floor beneath it, as in that 
way serious leaks of current are apt to occur. 

An insulated platform of wood with glass legs should be provided. 
While any wooden chair may be used, it is most convenient to have one 
of the adjustable reclining type made entirely of rattan in which no 
steel or other material is used. A second grounding must be made by a 
flexible chain which will reach to the treatment platform from as nearly 
as possible the opposite direction from the machine. 

Care of Apparatus. —The inside of the case must be kept as nearly 
damp-proof as possible by tightly fastening in each section of it. In 
addition it is necessary to keep drying material inside of both charger 
and plate sections. We use for this purpose wooden boxes, lined and 
covered with unbleached muslin and filled about half full of dry lump 
lime. The covering prevents the lime powder from being distributed 
through the machine. When this lime has absorbed moisture and has 
swollen to the size of the box, it should be refilled. Turrell uses for this 
purpose shallow basins partly filled with sulphuric acid. In particularly 


STATIC ELECTRICITY 


321 


damp weather, ice and salt may be used to condense what moisture has 
gotten into the machine. It is advisable on dry, sunny days to take 
off the ends of the case and admit fresh dry air. A yardstick wrapped 
in cloth and dampened with banana oil will clean and remove all moisture 
from the plates. After several applications, however, a film may form 
on them which requires removing by scraping. Each day the rods and 
terminal balls should be gone over with hot flannel cloths, keeping them 
bright and dry. 

Charging. —Place the charger chain on the opposite terminal after 
the ground wire has been removed. Turn down the charger rod, sep¬ 
arate the small terminals about half or three-quarters of an inch and 
turn the charger handle rapidly. After several minutes of spark dis¬ 
charge across the terminals, turn on the motor. If the spark discharge 
keeps up after charging rod and chain have been removed and continues 
when the terminals are separated two or three inches, the machine is 
properly charged. It may be necessary to repeat this procedure several 
times. If still unsuccessful, attention must be given to changing the air 
inside the case or cleaning the plates. 

Polarity. —Static is another type of current in which the polarity ef¬ 
fects are distinct and of great importance. There are three convenient 
tests for polarity. 

With a spark gap of about three-quarters of an inch, it will be 
noted that one end of the stream of sparks appears light in color; this 
denotes the positive pole. 

When the terminal distance is increased to three or four inches, this 
light color appears at the negative terminal. 

Perhaps the most reliable test is to separate the terminals some four 
inches, run the machine at full speed and approach the terminal with 
one end of a dry wooden stick. The most convenient rod to use is one 
from one foot and a half to two feet in length. The stream of sparks at 
the positive pole will follow the movements of the end of the stick, at 
the negative pole it will not. The differential polarity effects will be 
stated in a description of the separate types of current. 

It must be kept in mind that the polarity may become reversed. 
While this most often happens when the machine requires recharging, it 
will occasionally happen from dampness without apparent complete loss 
of charge. No static treatment should ever be given without the operator’s 
certain knowledge as to its polarity at that time. 

Physics and Physiological Effects. —The best types of apparatus de¬ 
velop a voltage ranging from 100,000 to 800,000 and an amperage of 
from % to 2 milliamperes. This extremely high potential and minute 
volume of current is not approached in any other type of electricity. 
As stated the main effect is that of tissue contraction, not alone confined 
to muscles. The current is diffused easily, rapidly and completely 


322 


ELECTKOTHERAPY 


throughout the entire body and through the air and other relatively poor 
conductors. This diffusion is dependent upon the second main quality 
of the current, namely, its tremendous voltage or potential and is shown 
by the raising on end of the hair, and in many other ways. This raising 
of the hair is due to the fact that, the hair being charged with the same 
polarity as the rest of the body, its free end is repelled by this like 
charge. In the contraction of muscle tissue it is not necessary to pay any 
attention to the motor point as the perfect diffusion and high potential 
affect the entire muscle and easily produce a good contraction. I have 
spoken in other sections of the often neglected but important point of 
reassuring the patient, especially when, for the first time, an electrical 
current is applied to him. There is no type of current in which it 
is so essential to perform this duty as it is in the case of those derived 
from the static machine. To carelessly inform a patient that he is about 
to receive some half million volts of electricity, without explaining the 
freedom from danger which the minute amperage of static assures, is to 
be unfair to him. Absolutely no ill effect, other than an unpleasant 
sharp minute blow from a spark, can be obtained from this apparatus. 
The spark is a cold one. The hand may be held between the terminals 
with impunity. Matches cannot be ignited in the pathway of the spark. 
Again, I repeat, it is the safest of all electrical modalities used in medicine. 

When giving sparks, I often explain to the patients that it has a 
slight stinging character, quite similar to snapping an elastic band on 
the skin, with no burn or after pain. It is often found that pain and 
tenderness from previous tissue engorgement is so greatly relieved that 
patients request more sparks rather than fewer. The other types of 
static, if properly given, are not in the least unpleasant. Some writers 
advise giving milder types first, even though they may not be as efficient, 
in order to accustom a nervous patient to the apparatus before using 
sparks. I have found this unnecessary and prefer to use very short 
indirect sparks, gradually increasing them to the required severity. This 
contractile effect is that of practically all types of static modalities 
and their minor differences will be described separately under each type. 

All static modalities raise blood-pressure somewhat and should be 
avoided in cases of marked hypertension. Its employment in low systolic 
pressure and associated conditions is distinctly indicated. 

The patient should remove all steel which touches the skin. Garter 
clasps, hairpins and steel-ribbed corsets should not be worn. Both 
operator and patient should lay aside their watches during treatments. 

Modalities 

The different types of current derived from a static machine include 
wave, sparks, effluve, induced, and simple charge. 


STATIC ELECTRICITY 


323 


Morton Wave. —The wave current has been termed ionic, molecular 
and mass massage. It is dependent for its effects upon the very power¬ 
ful and extremely penetrating vibrations produced. This perhaps most 
valuable of static modalities was first described by Morton in 1890. 
It is a decongestor of tissue, removing and, to some extent, breaking up 
exudate not yet firmly organized. For deep-tissue drainage no form 
of massage or contraction produced by other currents can approach its 
efficiency. 

Treatment Technic .—The negative pole is grounded, and the electrode 
connected to the patient is attached to the positive pole. The wave may 
be given with or without the use of Leyden jars. In commencing, the 
treatment should be moderate and the spark gap quite short. The best 
electrodes for general use are the composition metal, twenty-two gage, 
recommended for diathermy. A number of these may he cut in vary¬ 
ing sizes and shapes, using a clip to attach them to the wire or inserting 
a hook through a hole made in the longer turned-back end of the metal. 
A broad U-shaped electrode to exclude the patella is convenient for 
applications over the knee. One electrode may be slit from the middle 
of one end and overlapped to fit the point of the shoulder. It is not 
necessary to obtain the perfect contact required in diathermy, although 
a reasonably good contact and the use of warm soap lather makes the 
treatment more comfortable for the patient. Morton wave is never applied 
over bony prominences. 

The physiological effect of the current is modified by a number of 
factors. The best rate of spark jump and consequent tissue contractions 
is three to four per second. This rate is maintained when the spark 
gap is gradually lengthened by steadily increasing the speed of the plate 
revolutions. It is customary to find, in treatments of tender areas, that 
the patient’s tolerance gradually increases so that a wider spark gap 
with deepened effect can slowly be obtained without increasing dis¬ 
comfort. 

The local effect produced is proportionate to the width of the spark 
gap and inversely as the size of the electrode. A good insulation of 
the platform is essential to the securing of a good result. The length 
of the treatment varies from ten to twenty minutes. It is unwise to use 
the wave current in an attempt to break down organized exudate, such 
as that following a muscle bruise, unless it has been preceded by diathermy. 
Exudates near the smaller joints and in tendon sheaths are better 
reached by means of the static spark. Such organs as the liver, spleen 
and prostate may be easily and efficiently treated with the wave current. 

Sparks. —The sparks are applied to patients by the direct and indirect 
method. The direct method is not as efficient, is more stinging and 
painful and used only to reach deep-seated lesions. The platform is con¬ 
nected to the negative pole, the positive side grounded. The ball elec- 


324 ELECTROTHERAPY 

trode with handle is applied from the second ground chain for direct 
sparks. 

Indirect Sparks .—This is the method commonly used. Its effects are 
much more sharply localized than with the wave current, hut the effect 
of muscular and cellular contraction is much the same. 

Treatment Technic .—Snow connects the positive pole to a metal plate, 
some ten by fourteen inches placed upon the platform, and grounds the 
negative. Sampson, Turrell and others apply the shepherd crook from 
the negative pole to the platform with the positive not grounded. In 
every case the spark is given from the hall and handle from the second 
ground chain. The intensity of the spark may he modified by varying 
the speed of the machine, by opening up the main terminals or by draw¬ 
ing off part of the current through the operator’s foot, placed close to 
the platform or resting on the edge of it. The wider the spark gap 
and the faster the machine is run, the longer and more powerful will 
the spark become. The hook from the second ground chain should be 
attached to the ring on the handle just below the ball, and a loop of 
the chain held in the operator’s hand. If the grounding is good, he will 
feel no effect from the current as applied to the patient; otherwise a 
light cramping of the wrist will be felt, in which case the grounding 
should be changed. 

It is essential to deliver to the patient but one spark at a time. 
A shower of sparks on one area is unduly painful. Skill in accom¬ 
plishing this comes, of course, with practice, but may quickly be attained 
if the ball electrode is moved rather rapidly through a semicircle. When 
this is done, usually only a single spark will occur in that segment of 
the movement closest to the patient’s skin. One should pass by, rather 
than toward, the surface being treated. A series of running sparks 
may be given by rapidly moving the electrode parallel to the surface of 
the patient’s body and at the proper distance from it. Here the sparks 
on different parts of the surface are not particularly painful. Better to 
localize the spark, the loop-shaped director, recommended by Snow, is 
most valuable. In this case the semicircular movement may be described 
on the shoulder of the director several inches from the patient’s body 
and the effect is exactly the same. 

It adds greatly to the comfort of the patient if the sparks are given 
in regular rhythm so that he is prepared for the slight shock which they 
produce. Again, it should be emphasized that all organized tissue 
exudates should be treated with some effective form of heat before using 
sparks. Sparks are extremely unpleasant over bony prominences, and 
they should be avoided if possible. The relief from pain experienced 
after application of sparks to congested tissue is, in a large measure, 
that of the relief of pressure on nerve endings. Muscle spasm of many 
types, with its associated pain, is quickly relieved by sparks. Joint 


STATIC ELECTRICITY 


325 


sprains, without rupture of ligaments, are improved with astonishing 
rapidity. A certain general toning-up effect upon the general nervous 
system follows a treatment of sparks along the spine. 

Effluve. I he static effluve, brush, blue pencil or breeze, produces 
extremely mild and more or less superficial contraction of tissue. Its 
effect is distinctly sedative when given by the ordinary method. It may 
he made rather irritating when the electrode is applied closely, or through 
the clothing. The sensation which the patient receives is that of a cool 
breeze striking the skin. 

Treatment Technic .—The terminals should be opened to their fullest 
extent. The positive side is grounded. The shepherd crook, held by 
the patient or placed on the platform, is connected to the negative pole. 
Quite a variety of electrodes have been used in giving this form of treat¬ 
ment. The DeKraft pencil is to be preferred for all general use. It 
consists of a fiber cylinder filled with asbestos, at one end of which is 
a blunt brass point and at the other a ring for connecting it with the 
second round chain. Willow or ash sticks have also been used. Where 
it is desired to diffuse the effect produced, an ordinary whisk broom may 
be used as the electrode. A loop of the second ground chain should be 
held in the grasp, while the electrode or the chain may be partly wrapped 
around the operator’s body. The point of the electrode is held at a vary¬ 
ing distance from the .skin, depending upon the amount of current, usually 
about three inches away and moved rather rapidly by the flexion and exten¬ 
sion of the wrist. 

Boudet, of Paris, found that the area of superficial skin effect was 
about one and one-half times the distance between the electrode and the 
body. Therefore, it is concentrated by close approach. The bluish 
color which appears between the point of the electrode and the skin is 
probably due to electrified dust particles which become fluorescent. A 
crown piece with brass points on a stand may be used to localize the effect 
on the head, and when given to women patients all combs and hairpins 
must be removed, and the hair should be braided. It should be placed 
quite a few inches from the top of the head. The effluve current is 
especially useful in acute nerve pain, to gently remove tissue congestion 
over bony prominences and in locations where wave and sparks are diffi¬ 
cult to apply. A typical example would be its use to promote absorption 
of the hemorrhage in a case of black eye. The use of it to promote the 
healing of ulcers has been recommended, but this is better done by 
other means. Headache and insomnia, particularly when associated with 
low blood-pressure, are amenable to treatment by the static effluve. 

Induced Current. —This type of current, first described by Morton, 
is also used to drain tissues. It is applied by the bipolar method, the 
patient being connected with the outer two coats of the Leyden jars, 
the inner coatings of which are connected to the terminals. Its local 


326 


ELECTROTHERAPY 


effect is that of the static wave and it has a somewhat general tonic effect. 
It is easily applied to two parts at once, such as the two knees or bilateral 
muscle groups. The ordinary galvanic or high-frequency electrodes may 
he used. The terminals being first closed, and later opened to the re¬ 
quired distance, the patient receives unidirectional condenser discharges. 
It is not really a type of high-frequency current, as has often been 
supposed. 

The Simple Charge. —The use of the same machine “set” and technic 
as for effluve, hut without drawing off any of the current through the 
second ground chain, produces this type of current. The patient, there¬ 
fore, becomes highly charged, the current leaving his body by diffusion 
through the air. This current is used to promote sleep and to raise 
blood-pressure and for mild general tonic effects. 

The writer is aware of the supposed difficulties in the use of static 
electricity and that it has been hard to obtain simple concrete directions 
as to its use. He has attempted to supply these. The beginner in the 
use of static electricity will very quickly overcome his diffidence in 
handling the machine and become impressed with the results he is able 
to attain in properly selected cases. 


CHAPTER IX 


PHOTOTHERAPY 
Harry Eaton Stewart 

LIGHT-THERAPY IN GENERAL 

History. —The application of light in the treatment of disease is men¬ 
tioned in the earliest medical writings extant. It disappeared from me¬ 
dieval literature to reappear only shortly before the beginning of the last 
century. Among the early writers the French took a prominent part. 
About the middle of the nineteenth century we begin to find definite recom¬ 
mendations for the use of sunlight in tuberculosis, arthritis, rickets and 
other conditions. Toward the close of the century, Finsen and Rollier 
added much to our knowledge of heliotherapy. Recently, work of value 
has been done by T. Howard Plank, of Chicago; Edgar Mayer, of Saranac 
Lake; Major Chris M. Sampson, of New York; Virgil C. Kinney, of 
Wellsville, Hew York; A. J. Pacini, of Chicago, and others. In attempt¬ 
ing to simulate the healing power of the sun, Finsen, Arons and Cooper 
Hewitt did valuable research work. 

Physics. —It is extremely difficult to divide phototherapy into con¬ 
venient sections, since sunlight, radiant light and, to some extent, ultra¬ 
violet light overlap in both physics and physiological effects. A brief 
consideration, however, of the entire range of light vibrations will form 
a foundation upon which a short discussion of these individual differences 
may be based. 

There are light vibrations, invisible to the eye but potent in their 
physical effects, at both ends of the spectrum. Below the visible light rays 
are the hertzian waves of extreme length, up to several hundred feet, with 
slow vibration rate. These are the agencies concerned in wireless trans¬ 
mission. Hext we come to the infra-red or burning rays which range from 
900 down to 800 millimicrons in length and are quite penetrating and 
heating in their effects. The visible spectrum, ranging through red, orange, 
yellow, green, blue, indigo and violet color, extends from about 800 down 
to 400 millimicrons. Hext we enter the field of ultraviolet radiations. 
Those contained in unfiltered sunlight extend down to about 300 milli- 

327 


328 


PHOTOTHERAPY 


microns and the shorter wave-lengths derived from mercury quartz lamps 
range down to about 190. Beyond that lies a field of vibrations as yet 
unexplored and unknown, then the alpha, beta and gamma emanations 
from radium and, finally, the X-ray. There is throughout this entire scale 
a steady decrease in wave-length and a corresponding increase of rapidity 
of wave vibration rate. It may, in general, be stated that the hertzian 
waves are the most penetrating, X-ray and radium next, then visible light 
and, least of all, ultraviolet. With the exception that most experiments 
on ultraviolet penetration are based upon vascular red tissue, recent ex¬ 
periments are modifying our idea of the apparently slight degree of 
penetrability with which they have been credited. Many points in the 
physical effects of light are extremely involved and the writer is only 
attempting to describe the main effects in the simplest possible form. 

Penetrability. —Several investigators have claimed that red rays 
penetrate quite deeply into living tissue. Yellow and blue rays penetrate 
somewhat less and ultraviolet ordinarily do not go far beyond the super¬ 
ficial layers of the skin. Kinney and Shamberg have been able to effect 
photographic plates through the hand and through the cheek with ordi¬ 
nary incandescent light. By far the most painstaking and accurate ex¬ 
periments in the penetration of light have been done by Virgil C. Kinney 
and a thorough understanding of this subject is hardly possible without 
examining, at some length, his results. He built a lightproof box and 
with the use of carbonized putty was able while using it, both with the 
photographic film and the fluoroscope, to exclude completely all light not 
coming through the part under examination. In using the body of a 
fish he found the usually believed order of penetration, greatest with red 
rays and least with ultraviolet, to be reversed, and he concluded that there 
would be a uniform increase in penetrability from the red rays clear 
through to the X-ray, increasing in proportion to the rapidity of vibra¬ 
tion, except that the blood acts as a red filter screen especially to handi¬ 
cap the ultraviolet band. The conclusion has been confirmed by demon¬ 
strating the penetration of the ultraviolet rays with compression of the 
tissues, thus creating an anemic area in front of them. Light does not 
penetrate directly in proportion to the candle power, although with the 
more powerful lights it is somewhat greater in degree than with weak 
lights. Natural sunlight gives a greater amount of penetration than any 
artificial rays, except radium and X-ray. Of unusual interest are the 
results he obtained in the relative penetration of light through three hands 
from blond, brunette and negro which calipered to exactly the same 
thickness. In both fluoroscopic and photographic tests the penetration was 
greatest in the negro, less in the brunette and least in the blond individual. 
The human retina can detect light rays coming through which do not 
fog any photographic plates at present obtainable. He concludes that 
pigmentation is not a protective mechanism against light penetration, 


HELIOTHERAPY 


329 


but merely toughens the skin, and that the greater therapeutic results ob¬ 
tained in all irradiation of those who tan are due largely to the increased 
absorption they possess to the light rays. Light penetrates easily to an 
inch and an eighth, some to an inch and a quarter, but in none of his 
many experiments did any light penetrate an inch and a half of human 
tissue. He calls attention to the fact that this degree of penetration is 
sufficient to reach the surfaces of the smaller joints, to pass through a 
thin abdominal wall, and that it will certainly reach sinuses, the middle 
ear, some of the mastoid cells and other locations where clinically light 
has proved to be therapeutically effective. 

Absorption. —There can be no question that ultraviolet rays, whether 
obtained from direct sunlight or quartz lamps, are absorbed by the blood¬ 
stream, and set lip photochemical reactions throughout the body which 
have rather marked effects. The sensitization of cell protoplasm induced 
by the action of light vibrations on certain cells undoubtedly accounts 
for the lethal effect produced on bacteria. Sampson was able to affect a 
screened photographic film applied to one portion of the body after the 
exposure of another part to ultraviolet light. Many general effects re¬ 
sulting from exposure to the longer wave-lengths, typified by the red 
rays, are merely those of heating the blood-stream, although an increase 
in certain blood elements has been thought by some investigators to be 
present. Similar increases in the red and white cell count, however, have 
been found at high altitudes without exposure to the sun; also, after 
irradiation with sunlight or artificial light through glass in which the 
ultraviolet rays were entirely lacking, like increases have been reported. 
Much work remains to be done before the exact effect of light on the cir¬ 
culation is made clear in detail. 

Pigmentation. —This is to a certain extent a protective phenomenon 
on the part of the body evoked by all light, but most intensely proved by 
the action of ultraviolet light on the skin. The nature and etiology of 
the process is not yet well understood. 

With these few general considerations we will turn to the various types 
of light administration to the body and consider more in detail their dif¬ 
ferential effects. 


HELIOTHERAPY 

Sunlight contains a small percentage of red rays, some 80 per cent 
yellow and green, 5 per cent blue and a small and quite variable percent¬ 
age of ultraviolet. The ultraviolet rays are easily destroyed or made 
ineffective by moisture, dust and organic matter in the air. They are 
greatest in amount in the noonday sunlight. They vary with the season of 
the year and in general come through in richer amounts in high clear 


330 


PHOTOTHERAPY 


mountain air. It should he constantly kept in mind that the shorter rays 
will not penetrate glass or the thinnest cotton or silk cloth. 

Physiological Effects. —As would be expected, physiological effects 
vary somewhat with the varying ultraviolet content in the sunlight. The 
local effect upon the skin varies with the dosage. Laroquete has clearly 
described the effect of the solar rays on the skin as follows: When the 
exposure is mild in type and of short duration, there is produced a mild 
erythema which disappears after the exposure. If the duration is suffi¬ 
cient, this primary erythema remains and is due to the effect of the heat 
rays, similar in effect to those from hot air or other thermal sources. 
In longer and stronger exposures the epidermis is affected by the light 
rays, especially by the more rapidly vibrating ultraviolet band, produc¬ 
ing slight capillary extravasation of blood under the, skin and followed by 
pigmentation, varying with the intensity of the exposure. Still longer 
exposure results in a real dermatitis of painful type with exudation and 
exfoliation. Prolonged exposure gives a typical first degree burn with 
necrosis of the epithelium, congestion and dilatation of the blood-vessels, 
hemolysis, edema and extravasation of blood pigment into the tissues. Re¬ 
peated exposures of moderate duration, superimposing one burn on an¬ 
other, may produce an accumulative burn of considerable severity or the 
skin may become pigmented and immune from further burning. The 
general systemic effects of properly graded doses are, as a rule, an increas¬ 
ing hemoglobin percentage. The erythrocytes often show a steady in¬ 
crease. An immediate leukopenia is followed by a leukocytosis and 
gradual return to normal. There is a general increase in all the assimila¬ 
tive and eliminative processes of the body. Some of this general tonic 
effect must, undoubtedly, be attributed to the associated fresh air which 
patients under this type of treatment receive. 

Technic. —With properly constructed wind breaks, patients may he 
treated through a large part of the year even in a climate as severe as 
Hew England, providing they become hardened to it during the milder 
months. Special caution to prevent chilling is necessary at first. The 
head should be protected by a small screen. The treatments, to be ef¬ 
ficacious, require that practically the entire body be exposed to the direct 
rays of the sun. Leonard Woolsey Bacon, in his treatment of tuberculous 
ex-service men, has devised an inexpensive arrangement easily built on 
any hospital roof or porch. It consists of two long cross beams notched 
in pairs throughout their entire length to hold the handles of the ordinary 
army litter, with a circular head screen of wire covered with ordinary 
muslin which fits into the head beam. The portability, compactness and 
cheapness of such an arrangement should allow for the treatment of many 
patients at the same time, with the expenditure of very little money or 
effort. The initial exposure and amount of daily increment must depend 
upon the patient’s tolerance to the sun. The dark-complexioned stand 


RADIANT LIGHT 


331 


much more than the light or auburn type. The initial exposure is roughly 
four to ten times that of quartz light, and should vary from twelve to 
thirty minutes with five to ten minutes daily increment in those patients 
whose tolerance is built up rapidly by training. Another method of get¬ 
ting the patient accustomed to the treatment is to zone the body. Expose 
the leg, then leg and thigh, then the hips and so on, until the entire 
body, front and back, has been exposed. Maximum time may be extended 
to several hours, with those who tan readily. A cool sponge hath and 
brisk rubdown with a rough towel should follow all general treatments 
(for further details see article by Pryor). 

Mirrors may he used to concentrate the light effect in a shorter space 
of time. Direct exposure of the chest is avoided where there is any fever. 

Indications. —Heliotherapy will be found most' valuable in those 
localities where the sun is shining a large part of the time and where its 
rays are richest in ultraviolet light. It is indicated in practically all 
forms of tuberculosis with the exceptions noted above, in rickets, anemia 
and certain slow healing wounds. Certain investigators found that good 
results were being obtained in badly infected wounds in sections of South 
America, even in spite of lack of screening. Mayer calls attention to 
the part the air bath plays in the healing process. 

Contra-indications. —There are a number of conditions which either 
absolutely contra-indicate solar irradiation or modify very materially the 
amount of dosage ordinarily given. These conditions are: 

Active pulmonary tuberculosis associated with fever. 

Hemophilia and hemoptysis. 

Valvular heart lesions of any marked degree. 

Marked general nervous condition. 

Albuminuria to any considerable amount. 

Skins extremely sensitive to light show a solar eczema or Hutchin¬ 
son’s prurigo. 


RADIANT LIGHT 

Definition. —Radiant light consists largely of the luminous rays from 
the arc, carbon, tungsten or nitrogen filament lamp. This light, as gen¬ 
erated by the electric current, contains some of the infra-red rays and all 
of the wave-lengths of the spectrum. Since the filament lamps are always 
enclosed in glass bulbs, we may assume that no ultraviolet rays pass 
through the glass and reach the patient. The color of the- glass has 
probably but slight influence upon the therapeutic effect of the light. 
The rays transmitted through red glass are slightly more irritating and 
burning, while those through blue glass are less, irritating, and slightly 
analgesic. This selective effect of color, however, is greatly exaggerated in 
the claims made for certain lamps. 


332 


PHOTOTHERAPY 



Therapeutic Effect. —There can be no question of the fact that lumi¬ 
nous rays penetrate to a depth of nearly one and one-half inches through 

ordinary tissue and 
some writers claim far 
greater penetrative 
power. Almost all of 
the radiant energy is 
undoubtedly changed to 
heat in the tissues, and 
this heat is liberated as 
deeply as the rays pene¬ 
trate. Turrell states 
that in clinical practice 
he detects little or no 
difference between the 
effects of radiant heat 
administered by light 
baths and the effect of 
the convective heat of 
the hot-air bath, or con¬ 
ducted heat by means of 
the direct application of 
other substances to the 
skin. He states that the 
convenience of the elec¬ 
tric light as a mode of 
application is all that it 
Fig. 1.—Body Radiant Light Bath Cabinet. has to Commend it above 

the other methods. It 

is doubtful whether any other form of heat except diathermy penetrates 
actively vascular tissue to the depth of radiant light. The qualitative 
effect of light upon the skin and sensory nerve endings is probably definite 
and greater in the case of the radiant energies. Other writers, notably 
Kinney and Snow, state that the effects produced upon metabolism cannot 
be explained on the basis of the heat production alone. 

Local Effects. —These are mainly the intense stimulation of the skin 
and skin glands consequent upon the marked degree of hyperemia in¬ 
duced in the skin and subcutaneous tissue to the depth of the light pene¬ 
tration. The analgesic effect of light is very marked and constitutes one 
of its main therapeutic indications. This effect, too, is produced in pro¬ 
portion to the amount of heat developed. Its bactericidal effect, especially 
on anaerobes, is great, though this effect is less marked than with ultra¬ 
violet irradiation. A slight local pigmentation of the skin follows re¬ 
peated exposure to radiant light and is probably due to the blue and violet 









KADIANT LIGHT 


333 


rays; ultraviolet light, as before stated, not being present. Spasticity of 
superficial muscles may be greatly relieved. 

General Effects.— These are due to the liberation of beat and mild 
stimulation of the sympathetic nervous system increasing slightly all the 
metabolic processes of the body. The relief of deep-seated pain has been 
repeatedly demonstrated clinically, but a satisfactory scientific explana¬ 
tion of it has yet to be evolved. The claims made for the effect of lumi¬ 
nous rays upon the blood count are varied and for the present must he 
discounted. 

Apparatus. —A wide variety of radiant light apparatus is at present 
on the market, varying from small portable 100-candle-power lamps with 
reflectors, to 2,000-candle-power lamps 
on adjustable stands. Tor home use the 
smaller lamps are quite efficient, but for 
extensive clinic, hospital or office prac¬ 
tice, the larger lamps are to be pre¬ 
ferred. There are also available a num¬ 
ber of types of apparatus containing 
from two to sixteen small carbon bulbs, 
adjustable in various ways, to place 
over a certain part of the body. Some 
of them are well built with switches con¬ 
trolling a given number of lights, but 
they have been largely superseded by 
the use of the more powerful single 
bulbs. It is important that the re¬ 
flector should be so arranged that the 
light will be properly focused on the 
patient’s skin a given distance from the 
lamp, usually twelve to eighteen inches. 

If this focal distance is maintained, 
there is economy in the use of the lamp. 

For general body treatment, a large 
variety of bath cabinets have been man¬ 
ufactured both with and without reflectors and ventilation. The number 
of lights in these cabinets varies from forty to one hundred. The re¬ 
flectors used should be so arranged that the rays do not overlap. There 
is probably no particular advantage in having such a cabinet ventilated 
during treatment. Those cabinets in which the patient is placed in a 
horizontal position are to be preferred to other types. 

Carbon Arc Light. —This type of light is not glass covered and con¬ 
tains a certain proportion of ultraviolet rays. It has been developed by 
Finsen in the Copenhagen Institute. Flying particles of carbon prevent 
the treatment of patients directly under the light. Four telescopic tubes 






334 


PHOTOTHERAPY 


are used to convey the light to patients around the lamp. Its effect rather 
closely resembles that of sunlight. Since the apparatus is expensive and 
cumbersome, its use is decreasing and no further space will be taken up 
with the special technic involved. The writings of Mayer, Finsen, Hess 
and others are recommended to those who desire detailed knowledge re¬ 
garding the use of this type of lamp. 

Technic. —The type of lamp selected will naturally depend largely 
upon the indications presented. The 1,500 or 2,000-candle-power single 
bulb has several advantages. The patient may shift his position, both as 
regards distance and direction, without the help of the operator. Ho sat¬ 
isfactory general elimination, however, may be secured with the use of 
this type. The body cabinet bath alone will do this work properly. The 
distance should be determined by the skin tolerance to the candle power 
used. The time of the treatment depends not only on the indication 
but upon whether or not other types of heat, such as paraffin hath, sur¬ 
face high-frequency or diathermy, are to be used in conjunction with 
radiant light. Where the entire heat effect is to be derived from radiant 
light, from twenty to forty minutes is the rule; otherwise, as short a 
time as ten minutes may suffice. In the body cabinet bath it is well to 
keep the head constantly covered in a towel dampened with cold water 
and to terminate the treatment immediately when there is undue rise 
of temperature or pulse, or soon after profuse perspiration has developed. 
Twelve to twenty minutes should constitute the average treatment. Some 
mild tonic type of hydrotherapy or a rest period is advisable before the 
patient is allowed to go outdoors. 

Therapeutic Indications. —Radiant light is used as a preliminary 
measure to massage and other forms of physiotherapy. To relieve pain 
in a wide variety of conditions it has no equal in efficiency and ease of 
application. It is to he preferred to the old-fashioned poultice or its 
modern prototype in cases of local infection, preceding incision or the 
application of ultraviolet or X-ray. It is used to bring about surface 
hyperemia for greater systemic effect by absorbed ultraviolet rays, in prac¬ 
tically all general treatments from air-cooled quartz lamps. There are a 
few indications of special value which should be mentioned separately. 
In acutely inflamed joints where other physiotherapeutic measures can¬ 
not be borne, radiant light may he used for hours for its analgesic effect. 
In congestive pain in the middle ear or sinuses, prolonged treatment by 
light has proved very efficacious. In the relief of erythema solare, from 
prolonged sun or ultraviolet exposure, it has given good results. Pain 
following operative incision may be safely, conveniently and to a verv 
large extent relieved, by prolonged and distant radiant light application. 
The general indications for the use of radiant light as given are so many, 
it is so easy and convenient to apply and so therapeutically effective that 
it is certain to receive increasing attention and use. I have no hesitation 


ULTRAVIOLET, QUARTZ OR ACTINIC RAYS 


335 


in saying that, in general, radiant light is more effective and has none of 
the disadvantages of many of the forms of external heat application still 
so commonly used. 

Contra-indications. —There are no real contra-indications for the use 
of radiant light, except where its prolonged use might delay the application 
of the properly indicated surgical, medical or other physiotherapeutic 
measures. For this reason, if for no other, it belongs, together with all 
other potent physical agencies, in the hands of the physician. 


ULTRAVIOLET, QUARTZ OR ACTINIC RAYS 

Definition. —Ultraviolet rays are the invisible light vibrations, be¬ 
tween 400 and 100 millimicrons in length. 

History. —In 1892, 

Arons was able to elec¬ 
trify mercury vapor 
and produce a light en¬ 
tirely lacking in orange 
and red rays. Some 
years later, Cooper 
Hewitt perfected such a 
lamp in a glass vacuum 
tube. Heraeus, Kro- 
m a y e r and Nagel- 
schmidt were collective¬ 
ly responsible for the 
perfection of the quartz 
burner and the employ¬ 
ment of this lamp in 
therapeutics. The per¬ 
fection of the tungsten- 
mercury burner and im¬ 
proved methods of fus¬ 
ing quartz, making pos¬ 
sible applicators with 
various curves and 
angles and portable 

water-cooled lamps, are 

, , » Fig. 3.—Mercury-tungsten - Air-cooled Ultraviolet 

recent developmen s o Lamp with Rectifier and Local Applicator. 

great value. 

Physics and Physiological Effects. —Sunlight contains the longer 
ultraviolet wave-lengths, those down to about 300 millimicrons, the thera¬ 
peutic effect of which has been already considered in connection with 








336 


PHOTOTHERAPY 


heliotherapy. The mercury vapor quartz light contains these longer rays 
and, in addition, is rich in the shorter, more chemically active wave¬ 
lengths, running down to about 190 millimicrons. The still shorter 
vibration lengths are not yet available for therapeutic purposes. The pro¬ 
portion of ultraviolet rays in the common types of light have been tabu¬ 
lated as follows: 


Ultraviolet Rays in the Common Types of Light 


Type 

Per Cent 
Infra-red 

Per Cent 
Luminous 

Per Cent 
Ultraviolet 

Mercury Vapor. 

52 

20 

28 

Sunlight . 

80 

13 

7 

Carbon Arc Lamps. 

85 

10 

5 

Incandescent Lamps. 

93 

6 

1 




Penetration. —Ultraviolet rays, even in pure quality from an air¬ 
cooled lamp, only penetrate a very short distance, because of the red 
filter screen action of the hemoglobin before mentioned. Under com¬ 
pression from surface quartz applicators or other means, the depth of 
penetration is very much greater, probably one-half to one inch according 
to the completeness with which the tissue is made anemic. It must be 
recalled that these actinic rays will not pass through glass, paper, thin 
cloth or ointment, but will pass quite readily through sterile water. 

Variation. —-There are certain fundamental differences between the 
quality of lights which emanate from the water-cooled and the air-cooled 
burners. The radiations from the air-cooled lamp are predominantly the 
longer ultraviolet wave-lengths. They are more penetrating, are absorbed 
in larger amounts, and stimulate metabolic processes. 

From the water-cooled burner we get a larger proportion of the short 
or far ultraviolet wave-lengths. It is this band that is most actively 
germicidal. The penetrative power of these wave-lengths is not as great 
and they are not as stimulating to metabolism. 

With the use of either type of lamp there are certain factors which 
cause the expected result to vary. 

The dust, moisture and organic material in the air, which at times 
so markedly reduce the ultraviolet content of sunlight, may in like 
manner effect to some extent the quantity of ultraviolet irradiation the 
patient receives from the lamps. A more important factor is the varia¬ 
tion in and the amount of electrical current. A comparatively slight 
change in electrical strength may result in rather wide variations in ultra¬ 
violet output amounting at times to as much as 15 or 20 per cent. 

Local Effects. —These vary according to the make and type of lamp 
used, time, distance, and individual susceptibility of the skin to these ravs. 
Ordinarily, no heat is felt and no perspiration induced. The skin may 












ULTRAVIOLET, QUARTZ OR ACTINIC RAYS 337 

react all the way from the faintest erythema to a complete first degree 
burn. The latter is, however, the most severe local effect it is possible 
to obtain and is insignificant in comparison to overdosage by X-ray or 
radium applications. 

In moderately severe doses the following histological changes in the 
skin have been found. There is dilatation of both the superficial and 
deep skin capillaries. The epidermis may loosen and blister. The nuclei 
of the skin cells show division and the lymph spaces become dilated. In 
mild doses there is only a moderate dilatation of the capillaries. The 
erythema does not appear for several hours after the treatment, thereby 
differing from the heat erythema which appears immediately. Pigmenta¬ 
tion of the skin usually begins on the second or third day, is steadily in¬ 
creased by repeated doses and protects the skin from further erythema 
or blistering. The exact effect of the rays on cellular activity is not 
definitely known. The shorter wave-lengths are those which produce 
most marked changes in cell protoplasm. This is especially true of their 
effect on microorganisms. Bovie found that the paramecium, when ex¬ 
posed to sublethal doses of ultraviolet rays, became so sensitized to heat 
that they were unable to withstand for a full minute a degree of tempera¬ 
ture which was optimum for controls. He concluded that death was 
due to heat coagulation after sensitization by the light. Other investigators 
have found cell protein to he less soluble and more easily precipitated 
after exposure to light. Finsen confirmed the bactericidal action of actinic 
rays in his work with lupus. Bacteria have been killed at a depth of 
iy 2 millimeters and their virulence markedly diminished at a depth of 
4 millimeters. The tubercle bacillus loses its staining properties very 
quickly when exposed to ultraviolet rays and is killed in a short time. 

The skin dosage is roughly classified as stimulative (mild), regenera¬ 
tive (medium) and destructive (severe) erythema. 

General Effects. —It is extremely difficult to give a clear-cut and con¬ 
servative estimate of the general effects of ultraviolet light upon the body. 
We are eager to have our clinical results confirmed by exact scientific 
demonstrations hut unfortunately there is not, as yet, entire unanimity of 
opinion among those who have investigated this subject. It is, in gen¬ 
eral, found that there is an increase in the percentage of hemoglobin 
and in the erythrocyte count; a temporary drop in the number of white 
cells, followed by a fairly permanent increase, and a building up of the 
resistant forces of the body toward all types of' infection. This is the 
usual result reported also in the clinical use of general ultraviolet treat¬ 
ments. 

There is often a relief from pain out of proportion to the minute 
amount of heat produced and to the possible counterirritant effect of the 
erythema resulting. This may be due . to a selective action on sensory 
nerve endings. As a rule, patients sleep better after properly selected 



J?ig. 4. The All-mercury, Air-cooled, Ultraviolet Lamp with Rectifier and 

Counter Weight. 


















ULTRAVIOLET, QUARTZ OR ACTINIC RAYS 339 

dosage. There is usually some fall in systolic blood-pressure. The effect 
of rays absorbed in the blood-stream is, of course, diffused throughout 
the body. General metabolism and especially elimination seem to be aug¬ 
mented after general treatments. Again, let it be understood that, while 
these results are fairly constant and may in the majority of cases be ex¬ 
pected under proper technic, they are still somewhat empirically em¬ 
ployed. The work of A. F. Hess, of New York, Janet H. Clark and others 
on the subject of rickets has clearly demonstrated the effect of ultra¬ 
violet light on blood chemistry. A marked increase in the inorganic phos¬ 
phorus followed by rapid calcification of bone was shown after exposure 
to the ultraviolet light, in cases of rickets in both animals and children. 
The results obtained by general irradiation in tuberculosis must be ef¬ 
fected by means of rays absorbed and distributed by the circulation. 

Apparatus — Lamps .—We have available air-cooled lamps for general 
radiation and water-cooled lamps for local work, each provided with 
rectifiers for the alternating current. There are many varieties of stands, 
methods of counterweighting case adjustment, and other conveniences for 
the clinician’s use. Convenience, appearance, durability, power, etc., have 
each to be considered in choosing a given type of lamp. 

Burners .—The burner is the important part of the lamp. Some valu¬ 
able information regarding burners has been furnished by W. W. Coblentz, 
of the Bureau of Standards. There are two types of burners on the 
American market: one consisting of a vacuum arc in a fused quartz 
chamber, the arc discharge taking place between electrodes of liquid 
mercury—the all-mercury burner; the other type has metal lead in wires, 
sealed directly to the quartz burner. Within the burner the cathode is 
liquid mercury and the anode is a flat coil of tungsten wire which is at a 
low red incandescence when the burner is in operation. With tests made 
at about 300 watts, there seemed to be no difference in ultraviolet output, 
either in quantity or quality. It is possible that a difference would have 
been found with the use of heavier wattage. With the use of the 110- 
volt current, the intensity varied inversely as the square of the distance, 
while with the 220-volt current this variation was somewhat greater than 
the square of the distance, inversely. 

The greatest intensity is received on a surface parallel to the long 
axis of the burner and the oblique rays are noticeably less efficient. Small 
variations in the light voltage greatly change ultraviolet output. 
Burners having A. C. current operating through rectifiers last longer than 
those operated on D. C. Burners deteriorate steadily with use. This may 
be due to the ionized incandescent mercury vapor attacking and combin¬ 
ing with the quartz, forming dark deposits which may become porous 
and admit minute amounts of air which combine with the mercury. 
Burners deteriorate from one-half to one-third after some fifteen hundred 
to two thousand burning hours. As a rule, the lamp on a stand with 



Fig. 5.—Standard of the Water-cooled Ultraviolet Lamp with Rectifier. 











ULTRAVIOLET, QUARTZ OR ACTINIC RAYS 341 

castors is more convenient than one counterweighted from the ceiling. 
The manufacture of burners is a difficult and highly specialized task 
which makes them rather expensive. They have to be able to withstand 
a temperature of 3,700° F. 

Applicators .—For general needs, one large square applicator, a medium 
circular and a small circular applicator should suffice for surface work. 
They are also made curved to different degrees and will conveniently 
reach all parts of the gums for dental work. A nasal, tonsillar, vaginal 
and rectal applicator will complete the number absolutely necessary for 
cavity work. It is desirable in addition to have at least one small sinus 
applicator. New methods have made it possible to fuse quartz in such a 
manner that the rays are emitted in nearly full strength from the end of 
curved applicators. The rooms in which actinic rays are used must 
be frequently ventilated. 

The eyes of both the operator and patient must he protected from the 
ultraviolet rays, for they tend to set up a conjunctivitis. The manufac¬ 
turers provide glasses which are opaque to actinic rays, and they should be 
constantly worn. A little carelessness in this regard, after some familiarity 
with the lamp, is common and almost always results seriously. 

Care of Apparatus .—After the rectifier switch is turned on, the lamp 
is started by tilting the burner so that the mercury flows to the tungsten 
anode, forming a contact. The effect of this contact is temporarily to 
short-circuit the current and this is the point where the greatest drain 
on the current supply occurs. For this reason every circuit into which 
the ultraviolet apparatus is to be plugged should be heavily fused, at 
least to 30 amperes. When the lamp is tilted back to its former position, 
the current continues to pass through the vaporized mercury which, 
until thoroughly heated, has a high resistance to the current. It will 
be noted that the voltmeter registers only a small amount of current 
flowing. As the mercury vapor becomes intensively heated, the 
voltmeter reading increases and the light emitted by the burner becomes 
more intense. Hence, in all types of lamps, a preliminary burning time 
of from five to twelve minutes is necessary before a full quantity of 
ultraviolet rays are produced and this refers particularly to the shorter and 
more potent wave-lengths. The burner should never be touched with the 
hands but lifted or tilted, if necessary, by the metal shoulder. Clean the 
burner off daily with alcohol. With the use of the water-cooled lamp, it 
must be made certain that a free flow of water is circulating in the lamp be¬ 
fore it is turned on. If this is not done the burner will be destroyed in a 
very short time. For this reason it is safest so to arrange the water 
intake that either the inflow or the outflow is visible to the operator. It 
is well, also, to allow the water to run for a moment or two after the 
lamp has been turned off. One quick lateral or posterior tilting of the 
lamp is usually all that is necessary to ignite the mercury after the cur- 


342 


PHOTOTHERAPY 



rent is turned on. Once lighted, it should always be allowed to come 
up to maximum before starting treatment. During the treatment, the 
lamp should not be tilted to more than twenty degrees from the vertical 
plane. This deviation may, at times, be carried to forty degrees, but it 
is safer to adjust the patient’s position and attempt to maintain the lesser 
degree of tilting just mentioned. 


Fig. 6.—New Type, Portable, Water-cooled, Ultraviolet Lamp for Ward Work, 

Technic — Air-cooled Lamp .—The problem of accurately measured 
dosage in actinotherapy is a complicated one. Slow diminution of effect, 
due to prolonged usage of the burner, must be considered. The variations 
of atmospheric conditions and current strength modify the results obtained. 
Patients differ quite markedly in their skin reaction to the quartz light. 
There are a few persons, extremely susceptible, who have toward these 
rays an idiosyncrasy comparable to that exhibited by some toward cer¬ 
tain drugs. These patients develop an intense eczema which is difficult 
to allay. Within the range of what might be termed normal reactions to 


.....I!!!!!!!!!!!! I!!!!!!!!! i 


... 











ULTRAVIOLET, QUARTZ OR ACTINIC RAYS 343 

the average initial dose, we have three variations of intensity: mild, 
medium and severe. In addition there are three different skin doses, 
namely, stimulative, regenerative and destructive, any one of which it 
may he our aim to produce. 

A stimulative erythema is the creation of a faint blush after a short 
treatment at average distance. This produces superficial capillary en¬ 
gorgement, stimulates surface epithelium and is the degree used for most 
general treatments. 

The regenerative dose induces a deeper redness just short of blister¬ 
ing. It is destructive to surface cells, is stimulating to deeper-lying cells 
and produces marked capillary engorgement, with considerable absorption 
of rays. This dosage is used in most widespread inflammatory skin dis¬ 
eases and for cavity work. 

The destructive dose induces blistering and vesication of superficial 
layers of cells, entirely destroying them, but the deeper layers of the 
skin are markedly stimulated to multiplication and growth. Its use in in¬ 
fective and hypertrophic skin lesions gives us the desired sharp, intense, 
localized result. 

To provide a technic by means of which we may accurately grade the 
dose in its proper relation to susceptibility, the manufacturers have pro¬ 
vided a method for determining the lamp output. It consists of small 
pieces of sensitized paper which are exposed for fifteen seconds at a 
standard distance and developed in water, dried and compared to a vary¬ 
ing scale of blue, much as hemoglobin is commonly tested on a Tallgvist 
scale. Opposite each sheet of color the number of seconds required to 
produce a mild erythema in the normal skin is given. 

We then test the patient’s skin with a dermographic pencil to deter¬ 
mine its reaction. A white line appearing immediately after the scratch 
is normal, no result negative, and a red line active. The person showing 
a white after-line requires the average dose. When no reaction follows, 
increased dosage is required, while the red line indicates a skin which will 
burn easily. This skin reaction may vary in the same patient at different 
times. 

In the treatfnent of the average adult patient for general effect, an 
abbreviated schedule of time and distance for different grades of suscepti¬ 
bility with either type of lamp should prove useful and is appended. 

All-mercury Burner 


(Initial distance 18 inches) 


Skin Reaction 

Time 

Daily Increment in Seconds 

Negative . 

4 minutes 

40 

Average. 

3 “ 

30 

Active . 

2 “ 

15 















344 


PHOTOTHERAPY 


Tungsten-mercury Burner 


(Initial distance 30 inches) 


Skin Reaction 

Time 

Daily Increment in Seconds 

Negative . 

1 Y 2 minutes 

m “ 

50 seconds 

20 

Average. 

15 

Active . 

10 



The different regions of the body vary in their sensitivity to ultra¬ 
violet light. The front of the arms burn somewhat less readily than chest 
and abdomen. The back of the arms and legs require twice the average 
dose to produce an erythema. The back of the hands withstand several 
times the usual amount, while the palms and soles of the feet are very 
difficult to burn. 

Age has some relationship to skin sensitivity to the light. Infants 
require one-fourth, children one-third and the aged two-thirds of the 
average initial dose and daily increment. 

Eemales react to an exposure some 20 per cent less in time than that 
required to produce the desired degree of reaction in males. Blond 
types in both sexes are more susceptible than brunettes. 

It is not generally necessary to use any intensifying devices. De¬ 
sired intensification may be easily secured by lessening the distance, 
without the added wear and tear on the burner of the lamp. If an in- 
tensifier is used, it should never be applied until after ten or fifteen 
minutes of burning time. 

We have considered so far the problem of initial dosage. There re¬ 
mains to be discussed the problem of daily increment. This may be ac¬ 
complished by increasing the time of the exposure, lessening the dis¬ 
tance from the burner to the patient or by a combination of these two 
methods. Minor increases are better regulated by increasing slowly the 
time of exposure. 

The aim in most general treatments is to produce the mild erythema 
dose and increase the exposure as rapidly as tanning will permit. We, 
therefore, divide the body into two or four zones which are rayed suc¬ 
cessively. In this manner the unpleasant features of erythema have 
largely disappeared before that particular surface is again treated, and 
tanning is slowly developed with a minimum of discomfort or peeling. 
It is well, even when attempting merely this mild reaction, to explain 
to the patient that there may occur a real sunburn, because, in spite of 
all possible precautions, unexpectedly severe reactions occasionally occur 
and it is safer to have the patient mentally prepared for such an occur¬ 
rence. In those who burn but do not tan, the dose is naturally much re¬ 
duced and the daily increase very slight. Where smaller areas than a 










ULTRAVIOLET, QUARTZ OR ACTINIC RAYS 345 

full body zone are under treatment for more or less local effect and it 
is necessary to push the treatment, one burn may be superimposed on 
another with no danger other than the superficial skin destruction already 
described. The average daily time increase bears, of course, a general 
relationship to the time of the initial dose, ranging from 10 to 25 per 
cent of it. No increase at all may he possible in those who do not tan. 
It should be remembered that a lapse of several days during the treat¬ 
ment, especially if accompanied with peeling, will necessitate the return 
to pretty nearly the initial dose. In any prolonged general treatment it 
is well to drop back to almost the beginning dose and again work up, 
after a maximum of twenty to thirty minutes’ exposure has been reached 
and maintained for a short time. This is comparable to the giving 
of certain drugs in courses. Various unpleasant sensations are noted in 
patients who have been continued at general maximum treatment for a 
considerable length of time. 

In certain conditions, noticeably those of or complicated by pulmonary 
tuberculosis, both the zoning and the daily increase must be much more 
carefully worked out. In some conditions, and tuberculosis is a notice¬ 
able example of them, even the average initial dose of ultraviolet light 
may be followed by a rise in temperature. Most of those who have worked 
with the lamp in these conditions feel that this is not a necessarily dan¬ 
gerous or unfavorable reaction, but comparable to that following tuberculin 
or the use of certain vaccines. However, since a temperature rise of this 
type is the cause of a perfectly natural alarm on the part of workers 
not familiar with the use of the lamp and since we must be very guarded 
in pushing any new treatment, especially in active pulmonary cases, an 
effort should be made so carefully and gradually to grade the dosage as to 
ultimately attain the desired results without any undue rise of tempera¬ 
ture. Such a plan has been worked out and put in operation in our 
Service in the United States Veterans’ Tuberculosis Hospital at New 
Haven, by Major Leonard Woolsey Bacon, and is described in detail in 
the section on Applied Physiotherapy relating to Tuberculosis. 

Water-cooled Lamp .—This is used only on small areas for very in¬ 
tensive effect. It is the bactericidal effect of the short wave-lengths that 
usually recommends its use. For regenerative effect, treatment may be 
given through the quartz window at a distance of one or two inches from 
the skin, using exposures varying from thirty seconds to two minutes. 
For most surface work the quartz applicators mentioned are used. They 
should be carefully cleaned with alcohol before and after each treatment. 
All crusts, scabs, ointments and other foreign substances should be re¬ 
moved from the affected area before commencing treatment. Gentle, firm 
pressure is used, directed at right angles to the surface. The surrounding 
area of skin may be protected by zinc oxide plaster, ointment, towels or 
heavy black photographic paper. The time of exposure varies from 


346 


PHOTOTHERAPY 


thirty seconds to twenty or thirty minutes, depending upon the effect that 
it is desired to produce. In cavity work with the various special ap¬ 
plicators, one to two minutes is generally employed. Gentle, firm com¬ 
pression is also used on the gums, and one or two minutes with slight 
daily increase is the average time of the treatment. 

Pacini gives the exposure time required to kill various bacteria sus¬ 
pended in clear sterile water at 200 millimeters as follows: 


Seconds 
required 
to kill 


Diplococci 

Gonococci . 6 

Meningococci . 6 

Staphylococci 

Pyogenes albus . 10 

Pyogenes aureus . 12 

Streptococci 

Yiridans . 14 

Hemolyticus. 18 

Mucosus. 25 

Pneumococci 

Group 1. 25 

Group II. 20 

Group III. 25 

Group IV. 15 

Bacilli 

Influenza. 18 

Diphtheria . 10 

Tubercle . 12 

Lepra . 15 

Colon . 18 

Typhoid. 18 

Dysentery types . 20 


Treatment Precautions. —It is well to summarize a few of the im¬ 
portant points demanded by proper technic. Burn the air-cooled lamp 
not less than six minutes before starting treatment. Place the lamp so 
that the surface to be treated is well centered and parallel to the long 
axis of the burner. If applicators are used on the air-cooled light, as 
occasionally convenient, adjust the patient to the lamp and nearly double 
the time you would use with the water-cooled apparatus. After turning 
on the rectifier switch, see that the meter needle has moved on to the 
scale and not below zero. If the latter has occurred, reverse the wall 
plug before turning on the lamp. If the lamp has just been used and 
turned off, allow the burner to cool somewhat before attempting to relight 
it, after which it need burn only a moment or two to reach its maximum 
intensity. With the water-cooled lamp, be absolutely certain that the 
water is freely circulating before the lamp is turned on and, if possible, 




















ULTRAVIOLET, QUARTZ OR ACTINIC RAYS 347 

do not tilt it more than twenty degrees during treatment. Treat sunburns 
similarly to any mild first degree burn with radiant light at a distance. 

Therapeutic Indications. —One hesitates to name all the indications 
for the use of ultraviolet light, lest it be thought that he is advocating a 
cure-all, but the indications of proved value are many and include: 

Practically all local skin infections and simple alopecia. 

Sluggishly healing wounds. 

Burns of all types, including those from X-ray and radium. 

Chronic ulcers of the skin and mucous membrane. 

Sinuses of all types, where the area drained has been cleaned up. 

Deep-seated infections, such as osteomyelitis; tuberculous empyema, 
adenitis, arthritis, and peritonitis; sinusitis, pyorrhea, alveolar abscess, 
superficial tonsillar infection, the simple anemias and reduced hemoglobin. 

Pacini, in his text, has worked out in detail the hypersensitive skin 
areas occasionally encountered in organic and functional disturbances of 
the various organs and claims results from regenerative doses of ultra¬ 
violet light to these areas. The writer would refer those who desire to go 
more deeply into the possibility of inhibiting reflex pain to Pacini’s text. 

Contra-indications. —Ultraviolet light is usually contra-indicated in 
patients with extremely sensitive skins, in those with hemophilia and 
active febrile tuberculosis; in the last named at least as regards chest 
exposure. 

In the use of all types of phototherapy, particularly ultraviolet light 
both natural and artificial, we are employing a method of therapy, faith 
in which is deeply implanted in all conscious living things. Artificial 
production and refinements in technic have increased its availability and 
the potency of its application. Its wider use in therapeutics is certain to 
bring most gratifying results. The caution should be ever kept in mind 
that necessary surgery or supplementary hygiene and medication should 
never be postponed or omitted in connection with its employment in 
therapeutics. 


CHAPTER X 


THERMOTHERAPY 
William Benham Snow 

History.—Heat therapy or thermotherapy has, from the earliest rec¬ 
ords, been of established value in medicine. The old method of practice 
with the use of poultices, hot-water bags, hydrotherapy, electric pads and 
other applications of heat is of little avail as compared with the modern 
methods of administration in therapeutics, the blood-stream carrying away 
the surface heat of the older methods by convection. 

The modem methods employing radiant energy and diathermy have 
revolutionized the methods of thermotherapy. There are various points 
with reference to heat about which questions have arisen and there are 
authoritative demonstrations deciding some of them. The following quota¬ 
tions will settle some of the mooted questions. 

While all authorities recognize the fact that radiant energy produces 
heat, a question has sometimes arisen as to whether the term radiant heat 
is correct. Both the Century Dictionary and the Encyclopedia Britannica 
confirm the use of the term as correct and also the application of the term 
convective heat as applied to the carrying away of heat by the blood¬ 
stream. 

“Heat was formerly believed to be caused by an indestructible, ma¬ 
terial fluid called calories. It is now known to be not a substance but the 
energy of molecular motion consisting, in the case of a gas, of nearly 
uniform rectilinear motion with sudden changes of direction and velocity 
when the molecules come near enough to one another; in the case of a 
liquid, of irregular wanderings of its molecules; and, in the case of a 
solid, of orbital or oscillatory motions. This motion entirely ceases only 
at the absolute zero point. The temperature is in fact nothing but the 
amount of heat per molecule. 

“When heat was believed to be a substance, the radiation of heat was 
explained in the manner analogous to the abandoned emission theory of 
light as the actual transfer of the heat fluid itself; now, however, radiant 
348 


HISTOEY 


349 


heat is known to be the energy of heat transferred to the luminiferous 
ether which fills all space and also pervades all bodies. The hot body- 
sets the other particles in vibration and this vibratory motion, in the 
form of waves, travels in all directions with a velocity of about 186,000 
miles per second. If this radiant heat impinges upon a body, part of 
it may be absorbed or, in other words, the molecules of the body may 
themselves be set in motion by the ether-waves. There is no essential 
difference between radiant heat and light, both being forms of radiant 
energy, the ether-waves differing intrinsically, among themselves, in wave¬ 
length only, and thus producing different effects, heating, luminous, and 
chemical, in bodies upon which they impinge, according to the nature of 
these bodies. 

“The rays whose heating effects are generally the greatest are of 
greater wave-length than those which most affect the eye (light-rays) 
and have longer periods of vibration. Like light-rays, they may be re¬ 
flected, refracted, diffracted, and polarized. The quantity of heat of a 
body or the amount of heat-energy which a body gains or loses in passing 
through a given range of temperature is measured in thermal units— 
heat-units—that is, by the quantity of water which it would raise through 
one degree Fahrenheit; it is given by the product of its weight into the 
number expressing the range in temperature multiplied by the specific 
heat. In ordinary speech, heat and temperature are not distinguished.” 1 

“Since heat can be produced, it cannot be a substance, and since, when¬ 
ever mechanical energy is lost by friction there is a production of heat 
... we conclude that heat is a form of energy.” 

“In the strictest modern scientific language heat is used to denote 
something communicable from one body or piece of matter to another.” 

“Light: That which makes things visible; in physics it is that form 
of energy which acting upon the organs of sight renders visible the objects 
from which it proceeds. 

“The principal phenomena of light are grouped under the following 
heads: (1) Absorption or the transformation of the vibration of the ether 

into the molecular vibrations of the body upon which the light falls or 
through which it passes. The effect of the absorption of part of the light 
rays by a body is to give it color; thus grass is green because it sends back 
to the eye only the rays which together produce the effect of green, the 
other rays being absorbed; and a piece of red glass owes its color to the 
fact that it transmits only that part of the light whose combined effect 
upon the eye is that of red.” 2 


1 Century Dictionary—Heat. 

2 Century Dictionary—Light. 



350 


THERMOTHERAPY 


FORMS OF HEAT 

Three forms of heat, or methods of action of heat, are to be considered 
as applied to heat therapy— conductive , convective and conversive. 

Conductive Heat.—Conductive heat, in living creatures, is the trans¬ 
mission of heat through the tissues of the body, and is limited to the 
skin, because the circulating blood carries all excess, limiting penetration. 
All methods by which heated objects are applied directly to the surface or 
interior of the body are, therefore, very limited in their effects upon the 
tissues underlying the integument. 

Conductive heat is the least effective method of heat administration, 
the heat being carried away by convection whenever applied externally 
or internally to the skin or mucous surfaces. The parts exposed are 
promptly rendered hyperemic and the circulating blood conveys the heat 
on to the general circulation, to be replaced by blood flowing into the 
dilated blood-vessels at the normal body temperature. Thus the excess 
heat passes on by convection, and the tissues beneath the skin remain at 
about normal, rendering of little therapeutic significance applications such 
as hot-water bottles, poultices, douches, baths, hot packs, wet dressings, or 
electrically heated pads at temperatures that the skin will tolerate. Skin 
toleration to administrations of dry hot air at temperatures of from 400° F. 
to 500° F. is possible if the surface is protected by an absorbent, such as 
Turkish toweling, which will absorb the collecting moisture of perspiration, 
otherwise liable to boil and blister the skin. If it were not for this con¬ 
vection through the medium of the circulating blood, such applications 
would he impossible and conduction would occur as it does in the roasting 
of a dead animal. 

That there are undoubted benefits derived from external administra¬ 
tions of heat, even though convection carries away the excess, is conceded, 
and its therapeutic indications and significance will be considered later. 

Convective Heat.—Convective heat is conveyed from the surface, the 
rectum, bladder or vagina by the circulatory channels—arterial, venous 
and lymphatic, in all of which the currents are accelerated—to be dis¬ 
persed throughout the organism and eliminated by the natural channels of 
dissipation. The writer was the first to recognize the importance of the 
distinction between the therapeutic effects of external applications of heat 
and heat derived from radiant sources and believes that the first reference 
in medical literature 3 to the different effects was made by him in 1009. 
The following year Dr. J. H. Kellogg of Battle Creek published a small 
volume entitled Radiant Light and Heat and Convective Heat. 

In all methods of heat administration, conductive, convective, or con¬ 
versive, heat is dispersed by convection; for which reason it is necessary in 

3 Radiant Light and Heat and Convective Heat, page 93. 



FORMS OF HEAT 


351 


the many important therapeutic indications with heat therapy to prolong 
the administrations, as will be shown. 

Conversive Heat. —This is the heat produced in a body by the trans¬ 
formation of energy, that is, by conversion of radiant energy, electrical 
energy, friction, or any other expenditure of energy, thus inducing the 
degree of molecular motion or vibration in such a body, as respects fre¬ 
quency and amplitude, requisite for recognition as heat; for heat, as 
previously shown, is a form of vibration in matter. In other words, by 
the transformation of different forms of energy—mechanical, electrical, 
radiant, or chemical—heat is evolved. 

The methods of employing or inducing conversive heat which are of 
importance in therapeutics consist in the regulated employment of radiant 
energy from luminous sources, as from the sun, from various types of 
artificial light-applicators, and from the passage of electrical currents 
through the tissues—thermopenetration or diathermy. 

When radiant energy passes through a transparent medium which 
offers a minimum of resistance, as in case of the sun’s rays passing through 
ether, air, or glass, little or no heat is evolved. When the radiations 
impinge upon matter that offers resistance, heat is produced by transforma¬ 
tion into heat energy by conversion. The earth’s atmosphere is heated by 
convection from the heated surface of the earth. 

Of the sun’s rays that pass through the glass window-pane, only the 
ultraviolet are absorbed, and those rays are of so great frequency and short 
wave-length that little or no heat is produced. When light of considerable 
candle power is passed from within a blue glass bulb, it becomes very hot 
from absorption of the luminous radiations or frequencies. 

The absorption of the ultraviolet rays by glass renders heliotherapy 
by the sun’s rays a farce except in the open air. Dr. Hess found it 
necessary to make this observation when considering an erroneous reference 
to the treatment of rickets through the glass windows of a solarium. 

In the work of an eminent author an illustration appeared, showing 
a patient receiving heliotherapy through a closed window. This is men¬ 
tioned to emphasize two facts: (1) that ultraviolet rays do not pass through 
glass; and (2) that heliotherapy is always presumed to be taken in the 
open. Furthermore, if the housewife is to derive in her apartment the 
beneficial sterilizing effects of the ultraviolet rays, the sunlight must enter 
through the open window. 

The 'penetration of the visible spectrum of radiant energy from lumi¬ 
nous sources is the same from all sources of white light. The radiation 
of one candle will be projected as far as that from a source of greater 
candle power, but with an intensity relative to the volume of light passing. 

The rays of the solar spectrum vary in penetration, heat production, 
warmth, wave-length, and frequency, the penetration increasing with the 
wave-length from violet to red and diminishing with the frequency from 


352 


THERMOTHERAPY 


red to violet. In other words, “the penetration is as the wave-length 
and inversely as the frequency.” When an electric light is held in the 
mouth or observed through the hand, the visible rays that appear in 
greatest abundance are the red. 

Of the greatest abundance and increasing wave-length are the in¬ 
visible infra-red rays, which pass to a much greater depth into the tissues 
than the visible rays, and are, therefore, of greater value in point of heat 
production than the visible spectrum. There is a marked difference in 
the extent or degree of penetration of the radiations from various artificial 
sources of light, those from the electric arc and carbon filament incan¬ 
descent lamp being richer in infra-red and red rays than those from 
tungsten lamps. The former also are properly the deeper therapy lamps. 
There are no “deep therapy lamps” except in conformity with the physics 
of light, though commercial nomenclature has sometimes assumed the 
contrary, thus misleading the uninformed purchasers of apparatus. 

The demonstrated penetration of the tissues by the radiations of the 
visible spectrum is about one inch, varying with the density and vas¬ 
cularity of the tissues—fat being least resistant and muscle and bone 
most resistant. Bone is no more resistant than muscle, as it is readily 
demonstrated that the visible incandescent rays penetrate the antrum and 
sinuses. If so, they also penetrate the mastoid and to the middle ear, 
a fact which is furthermore clinically verified. It is plain from the pre¬ 
ceding that reflected light is available for producing heat in the tissues 
to a considerable depth, the energy naturally waning as the radiations 
proceed. 

For therapeutic purposes the radiations should be projected from arti¬ 
ficial sources in practically parallel or slightly divergent beams. Focused 
or convergent radiations are too intense to be endured and, therefore, are 
not practical, and yet manufacturers have long persisted in putting on the 
market lamps that always reflect a focus. 

Induction of Connersive Heat .—Induction by high-frequency electric 
currents is a subject of profound interest in the light of accumulated thera¬ 
peutic accomplishments. 

All electrical currents produce heat as they pass through matter, the 
degree of heat varying with the amperage, potential, frequency, resistance, 
and directness of the current or conductivity of the path. The constant 
(galvanic) current of sufficient wattage, that is, volts times the amperes, 
to produce thermic effects of therapeutic value in the tissues is destruc¬ 
tive to the life of the tissues acted on, and is, therefore, out of consideration 
as a means of producing heat effects, except for the local destruction of 
neoplasms. The static, sinusoidal, and induced currents fill other roles 
in therapeutics, not essentially thermic. 

D’Arsonval Currents. —These currents are variously produced by 
many types of high-frequency apparatus, including open and closed circuit 


FORMS OF HEAT 


353 


transformers, Ruhmkorff coils, and static machines in combination with 
two condensers, a solenoid connecting the condensers and a variable spark 
gap, all in circuit. Types of apparatus for producing these currents now 
on the market are too numerous to mention. 

D’Arsonval’s original apparatus consisted of a Ruhmkorff coil, two 
Leyden jars, and a coil of several turns connecting the outer coatings of 
the two jars, the inner coatings being connected with opposite terminals 
of the Ruhmkorff coil. Between current terminals connected with the 
inner coatings of the two condensers—the jars—was an adjustable spark 
gap that could be lengthened and shortened, so varying the resistance in 
the circuit to vary the dosage. The current thus produced, when passed 
from the terminals of the resonator, solenoid, or coil through connecting 
cords to electrodes, is oscillating or alternating in character, at a rate of 
oscillation giving a frequency of more than 10,000 per second. There are 
two oscillations in each frequency. When the frequencies exceed 10,000 
per second, muscular responses cease, and the only appreciable effect to 
the senses is heat, if all contacts are closed and no sparking occurs in the 
circuit except at the spark gap. The only possible accident that can 
occur is from an excess of heat relative to the size of the electrodes, or 
from careless removal of an electrode, by the patient, when the current 
is in operation. 

Nagelschmidt first demonstrated that, with a powerful current passing 
between the two poles, there was no electrolysis—from a KI solution, 
iodin was not thrown down. Tesla demonstrated that with tremendous 
potentials there was no danger to life. 

With the modern types of transformer apparatus, provided with multi¬ 
ple spark gaps and with means of control, provisions exist for scientific 
methods of producing with safety and practical utility therapeutic admin¬ 
istrations of conversive heat into the deepest recesses of the body. 

Direct or Bipolar D’Arsonval Current. —This term was first used by 
the writer in the second edition of his work, High Potential Currents 
of High and Other Frequencies , published in 1910, and there described. 
The term is still in common use and interchangeable with those of thermo¬ 
penetration and diathermy —heating through—applied to this method of 
heat therapy. 

The passage of the current through the body was also designated by 
the author as the direct d’Arsonval method, in contradistinction to the 
indirect method or autocondensation, when the patient is connected to one 
pole and insulated from the other on the couch. The passage of the 
high-frequency current evolved by the d’Arsonval method or diathermy 
heats the tissues to practically a uniform degree in the path between two 
electrodes, placed on opposite surfaces, if the surfaces of the electrodes 
are practically parallel, so that the margins nowhere approach each other; 
otherwise the current would take the shortest route, following the path of 


354 THERMOTHERAPY 

the least resistance, and the effect would he greater from the contiguous 
margins. 

The heating of the tissues is derived in accordance with Joule’s law 4 
of conservation of energy. It is questionable whether all of the heat is 
produced by the resistance of the tissues to the passage of the current in 
the fulfillment of that law, or whether the joint action of the rapid oscilla¬ 
tions at a rate of frequency and amplitude comparable to heat account in 
part for the heating. This latter view is suggested by the conservation 
of a reasonably small current of very high voltage passing into the resona¬ 
tor, as compared with the meter readings. In one of his early experiments 
the writer derived a hot wire meter reading with the d’Arsonval arrange¬ 
ment connected with an 8-plate static machine of 225 milliamperes, 
whereas the current output of the machine did not exceed % milliampere, 
but was of very high potential. Under these conditions it would seem 
that the conservation may be due in a measure to induced current oscilla¬ 
tions that represent the amplitude and frequency characteristic of the 
vibrations of heat. A hot wire meter is calibrated with a constant cur¬ 
rent meter, with the constant current passing through the two meters. 
The meter readings, however, from the passage of the high-frequency cur¬ 
rent through the hot wire meter, do not conform in terms of current 
strength to the constant current readings, but in terms of heat. 

That the heat effect is practically uniform between two electrodes 
of equal size is readily demonstrated by cooking a thick piece of meat 
or a potato between two small disc electrodes, when, with sufficient cur¬ 
rent for the requisite time, it will be found, on cutting through a section, 
that in either case the cooking process has been practically uniform from 
side to side. 

When applied over the skin, which is more resistant than any other 
structure in the path, except possibly the outer thin compact structure 
of bone or of ligament, any temperature that will be tolerated by the 
skin is negligible as to any danger to the underlying structures. 

Physics. —The physical characteristics and the physiological effects 
of heat may be considered as depending upon: (1) local effects as applied 
to the surface of the body, whatever the source of the heat; (2) the reflex 
effect derived from the stimulation of the nerve end plates as affecting 
the deep centers with the derivation both of local effects and stimulation 
of the vital processes of respiration and circulation; and (3) the thermic 

4 “When heat is transformed into any other kind of energy, or vice versa, the 
total quantity of energy remains invariable; that is to say, the quantity of heat 
which disappears is equivalent to the quantity of the other kind of energy produced 
and vice versa. 

“The number of units of mechanical work equivalent to one unit of heat is gener¬ 
ally called the mechanical equivalent of heat, or Joule’s equivalent, and is denoted by 
the letter J. Its numerical value depends on the units employed for heat and 
mechanical energy respectively. 




FORMS OF HEAT 


355 


effects of the heated blood-stream as activating the general functions and 
activities of the organism. 

Effect of Local Stimulation .—Local stimulation by heat or cold of 
the peripheral nerves is followed by a prompt reflex response of the 
vasomotor mechanism, with an increased flow of blood to the tissues stimu¬ 
lated, following the natural law of reflex response to stimulation. Hyper¬ 
emia, promptly induced, is the natural phenomenon for the preservation 
of the tissues from burning through the application of heat, or freezing 
through exposure to cold. This is observed in the intense redness of the 
skin when exposed to radiant heat or conductive heat and in the reaction 
to cold with intense hyperemia. In both cases the natural reflex response 
serves to maintain the skin at the normal temperature. The influx of 
blood at normal temperature maintains the temperature of the skin at 
the temperature of the blood-stream as long as the body’s reserve is ade¬ 
quate to meet the requirements. In the case of exposure to heat, the latent 
heat of absorption from the evaporation of perspiration is an added 
source of protection, also favored by the hyperemia produced as an ex¬ 
ample of the efficiency of these natural provisions. We have a significant 
example of this in the therapeutic administration of dry-heat at 400° 
to 500° F. when, by means of the absorption of perspiration by Turkish 
toweling wrapped about a part, the skin is protected from collection of 
perspiration, and from consequent heating and burning of the surface. 

The local effects of heat as shown are: (1) to induce an active local 
hyperemia; (2) to increase the elimination of moisture through the sweat 
glands and of sebum through the sebaceous follicles; and (3) to expand 
or relax the tissues, thus relieving skin tension, pressure and pain. 

Reflex Effect on Deep Centers. —The reflex effect on the deep spinal 
centers is one of the most remarkable and beneficial effects of intense 
heat superficially applied when the powers of resistance are lowered, or 
of the stimulating effects of cold to the surface when the resistance is 
adequate to respond. The response to both heat and cold is the accelera¬ 
tion of the heart’s action and respiratory movements to meet the increased 
demands on the body’s energies. As illustrating the first type of responses 
I will cite the recovery of a patient whose condition was critical. 

The following observations made by the writer, with Drs. Grad and 
Munday, would seem to fortify this hypothesis. A patient in extremis 
from general septicemia, three weeks after a difficult surgical operation, 
with the characteristic feeble pulse, livid countenance, and a temperature 
of 105° F., was wrapped by the usual method in Turkish toweling and 
placed in a body hot air apparatus at a temperature of 300° to 350° F., 
and after thirty minutes removed with a full strong pulse, a marked 
hyperemia of the skin, and mouth temperature of 103° F. Eight hours 
later the temperature was normal, and the patient was convalescent in 
ten days. This extraordinary result could only be explained by (1) the 


356 


THERMOTHERAPY 


induction of an active phagocytosis with a positive chemotaxis; (2) stimu¬ 
lation by heat of the deep spinal centers, particularly the cardiac and 
respiratory; and (3) the elimination of toxins and other bodies through 
the agency of the profuse perspiration induced by the high temperature. 

Another case reported illustrates remarkably the result of peripheral 
heat stimulation as follows: 

“Dr. Herman Grad reported a case, that of a child who was brought 
into the Women’s Hospital in a state of collapse. The light bath as de¬ 
scribed was placed over her body, when a prompt reaction and improve¬ 
ment was set up in her physical condition. The diagnosis of the case was 
rendered uncertain, the state of collapse forestalling an exploratory opera¬ 
tion. It was found that, if the light was continued, she was revived, the 
low condition returning if it was discontinued. The light administrations 
were accordingly continued for several days, when unexpectedly the child 
passed from the rectum several inches of the small intestine. The case 
had been one of intussusception. The patient made a complete recovery, 
which would have been impossible except for the employment of radiant 
light and heat during the state of collapse.” 

These cases are remarkable examples of the profound therapeutic 
effects derived from the administration of heat to the periphery as a 
means of maintaining or restoring the vital processes. It is by this 
principle, as will be shown later, that heat contributes to the revival 
of the functions of the heart, as stimulated from the periphery in condi¬ 
tions of failing heart in the asthenic type of fevers, such as pneumonia. 
For the same reason, its administration is contra-indicated in decompen¬ 
sated valvular heart lesions. 

The reflex effect of the cold plunge or shower in the conditions of 
health is refreshing, and, if these measures are systematically used, the 
vigor of the circulation and peripheral resistance against exposure to cold 
are increased. 

Thermic Effects .—The thermic effect of convective heat, as affecting 
the increased heat carried by the heated blood to all parts of the body, 
is to increase the general metabolism of the organism by accelerated cir¬ 
culation of the heated blood, with general increase of elimination through 
the urine and perspiration, with solids in solution. A general condition 
of well-being is also induced, due to the increased activity under heat 
stimulation of the body’s functions, when not continued to a degree of 
overstimulation which will depress or overfatigue the cells of the body. 

Action of Conversive Heat. —The action of conversive heat is quite 
different, applied locally for therapeutic purposes, from the action of 
either convective heat or conductive heat. The object and purpose of 
administration of radiant light and heat is to produce a local penetrating 


HYPEREMIA 


357 


effect, with absorption of radiant energy for the relief of local conditions. 
The indication of first importance for its employment is the induction 
of active local hyperemia in the tissues beneath the surface. 


HYPEREMIA 

Hyperemia, induced by radiant energy and high-frequency currents, 
will be found to fill one of the most important fields in physical thera¬ 
peutics. The three significant effects of hyperemia, superficial or deep, 
are: (1) increased nutrition to tissues that are impaired, from the pas¬ 
sage of nutritive pabulum in the blood-stream to the parts; (2) increased 
metabolism from the activation of fixed cells under stimulation of the 
energy applied, and from the effects of the activated blood-stream; and 
(3) increased phagocytosis from the greater number of phagocytes con¬ 
veyed into the tissues, with a probable increase in chemotaxis. 

1. Increase of Nutrition. —The attending increase of nutrition is 
favored by increase in both the anabolic and catabolic processes, by which 
waste matters are hastened on from the lymph spaces through the lymphatic 
channels, and by the greater activity of the end organs in appropriating 
the nutrition. Elimination, promoted by the increased activity of the 
sweat glands and increased elimination by the other emunctories, is 
excited by the heat of convection as conveyed throughout the organism. 
By the administration of conversive heat the heated blood-stream conveys 
excess heat by convection, thus equalizing the temperature throughout 
the body by evaporation and cooling at the surface. There is local in¬ 
creased circulation in the tissues throughout the paths of the high- 
frequency current and to the depth that radiant energy penetrates, and 
the fixed tissue cells will be heated by the direct action. By the warming 
of the tissues and the passing of fluids in the fields so energized, the ana¬ 
bolic processes of nutrition will be accelerated and local tissue building 
or repair will be stimulated. 

In the authorized translation of Bier’s Hyperemia as a Therapeutic 
Agent , published by A. Roberts, 1905, the subject of hyperemia is treated 
largely from the point of view of a measure capable of effecting the 
destruction of bacteria, and acting* as a solvent to promote absorption. 
He refers also to its nutritive effects. In this work, however, he lays 
greatest stress upon its effects upon conditions of local stasis, although 
these are better managed by electrostatic modalities which produce tissue 
drainage. The failure of application of heat to remove infiltrating 
materials where marked stasis exists has been generally established. By 
the mechanical effects of the whirlpool bath it is often possible to relie\ e 
to a degree the infiltration from swollen stumps; but in general the 


358 


THERMOTHERAPY 


application of heat for restoring circulation and nutrition, where stasis 
is firmly established, must he conceded as ineffective. 

2. Metabolic Effects. —These, as shown, are the effects upon which 
increased nutrition depends and are, therefore, considered conjointly. 
Willy Meyer says “hyperemic treatment has been found most useful in 
that it favors the absorption of exudates and pathological tissue changes 
of various kinds. There is no other method that is superior to hyperemic 
treatment in point of gentleness and painlessness of application, as well 
as a tendency to relieve pain.” The field of indications for the employ¬ 
ment of hyperemia for increasing tissue metabolism is one of the leading 
indications for the use of thermotherapy. 

3. Effects of, on Infection. —Such effects constitute important indi¬ 
cations for the use of measures which induce this physiological effect. 
In this connection it will be observed that these effects are not alone due to 
the increased influx of blood with an increase in the number of phagocytes 
in the tissues, hut that certain bacteria, which are susceptible to heat or 
light are destroyed in situ ; an effect of conversive heat of great value 
in the treatment of local infection. The writer has shown in his previous 
contributions to this subject that some types of infection, notably the 
staphylococcic, streptococcic, and gonococcic, are affected locally by the 
administration of radiant energy, due probably to the combined light and 
heat effects. The ultraviolet rays, while only mildly thermic, are the 
great natural antiseptic, acting to destroy all forms of germ life with 
which they come in contact. It is a beneficent fact that the ultraviolet 
radiations destroy germ life on the earth’s surface and in water exposed 
to the sun’s rays. 

In acute and subacute infectious conditions alone, or in connection 
with other measures which inhibit germ processes or increase local hyper¬ 
emia or both, it (1) increases local hyperemia in the region of infection 
with a relative increase of leukocytes—the phagocytes; (2) inhibits-the 
activity of the germs through the intensity of the radiant light and heat 
radiations; and (3) stimulates the elimination of toxic materials, local 
and diffused, by the induction of perspiration and increase in tissue 
oxidation. By these means local phagocytosis is stimulated, the germs 
inhibited and devoured, and the toxic material eliminated. 

Derivative Effects. —These are induced when extensive exposures are 
made, rendering the surface hyperemic, through prolonged application of 
high-candle-power incandescent lamps over front, back, and sides, or by 
the arc or incandescent light bath, and through the coincident profuse 
perspiration induced; (1) lessening the quantity of blood in congested 
regions and the larger arteries and veins; (2) lowering arterial tension; 
(3) relieving an overworked heart; and (4) coincidently promoting ex¬ 
tensive elimination of the retained products of poor metabolism. 

There are several possible factors which may be active in effecting 


HYPEREMIA 


359 


the resolution and healing of septic processes as induced by the adminis¬ 
tration of hot applications: (1) The increased hyperemia occurring with 
tissue relaxation, which is present during the early part of the heat 
administration, brings into the involved tissues a greater number of leuko¬ 
cytes in proportion as the volume of arterial blood is increased, together 
with an increased amount of oxygen, so essential to local metabolism 
and prompt diapedesis of the leukocytes. (2) The profuse local and 
general perspiration induced alters toward normal the fluids in the field of 
involvement and coincidently eliminates, to an extent, other materials 
affecting the constitutional condition of the patient, possibly favoring a 
general phagocytosis. (3) The action of heat upon the superficial tissues 
may coincidently inhibit the activity of the microbes, or, by altering the 
constitution of the fluids, as suggested, produce a larger degree of positive 
chemotaxis. (4) The production of more active metabolism in the tis¬ 
sues will tend, also, to increase the natural fortifications of the involved 
tissues, increasing the activity of the macrophages. 

Zinsser says of Chemotaxis: “The motion of the leukocytes toward 
the invading substances indicates a sensibility on the part of the cell to 
changes in its environment incited by the foreign agent, and since the 
stimuli most likely to reach the leukocytes and bring this alteration in the 
direction of their movements are chemical in nature, the phenomenon is 
spoken of as ‘chemotaxis.’ . . . Since the change of direction brought 
about in a moving cell by such influences may be such as either to attract 
or to repel, the term ‘positive chemotaxis’ is used to designate the former 
and that of ‘negative chemotaxis’ the latter. The property of chemotaxis 
is of vital interest in the present connection, since, whatever may be our 
opinion regarding the relative values of phagocytosis and serum pro¬ 
tection in immunity, the great importance of the phagocytic process cannot 
be questioned, and any agency which repels the approach of the phago¬ 
cytes must be a detriment, while any factor which attracts them is, of 
necessity, a powerful means of defense.” 

Willy Meyer says: “Since it has been demonstrated that, by increas¬ 
ing the inflammatory symptoms, a beginning infection can be made to 
subside, we ought more generally to practice abortive treatment of in¬ 
cipient troubles of this kind; for instance, of incipient phlegmons or 
furuncles. 

“While it is not possible to suppress every infection before pus is 
formed, there is no question that, by means of artificial hyperemia, sup¬ 
puration can be avoided in a larger percentage of cases than by any of 
the other therapeutic measures at our disposal. 

“In cases in which suppuration is unavoidable, even with the aid of 
artificial hyperemia, owing to the intensity of the infection, Bier’s treat- 


360 


THERMOTHERAPY 


ment enables us to accomplish with small incisions what formerly could 
be achieved with large ones only. This has been shown by manifold prac¬ 
tical experiences. The advantage is obvious. 

“The increased supply of blood hastens markedly the course of a 
suppuration, inasmuch as it favors the rapid development of demarca¬ 
tion and separation of necrosed portions in soft tissues as well as in 
bones.” 

Advantages of Hyperemia. —The advantages of hyperemia produced by 
conversive heat, or diathermy, are marked as against the Bier method em¬ 
ploying of dry heat—the method referred to in the previous quotation by 
Willy Meyer. Penetration deep into the infected areas relieves many cases 
in which the heated air method will fail, and, furthermore, largely limits 
suppuration instead of favoring it, as stated by Willy Meyer. This is 
accomplished by bringing the large number of phagocytes into the in¬ 
fected field under conditions of light and heat unfavorable to the bacteria, 
and so terminating further developments. 

Erom the foregoing physiological effects, and from the effects of heat 
therapy upon bacteria, we have a foundation upon which the principles 
of heat therapy are well established. 

Heat in one form or another has been used in therapeutics since the 
earliest times. It is not probable that any measure that gives so much 
relief from pain as heat could have failed to be recognized by intelligent 
human beings. 

The sun’s rays, in the form of sun baths, were naturally the first source 
of heat employed. It is surprising, however, how little their effects have 
been understood. 

On the field of battle, where the wounded lay in the sun’s rays and 
were relieved from degrees of suffering, it must have been generally appre¬ 
ciated, except for the discomfort caused by continuous exposure to extreme 
heat. It is natural for all forms of life to withdraw from the intense heat 
of the sun’s rays at midday. Nor has the therapeutic value of radiant 
light and heat as derived from artificial sources been duly recognized. 
Its effects are often not appreciated except by those trained in the indica¬ 
tions and methods of application. Poultices, hot baths, Turkish and Rus¬ 
sian baths, mud baths, emplastrums, liot-water hags, wet dressings and 
hot douches are measures which have been in common use for many gen¬ 
erations. These forms of application act upon the surface and are all 
subject to the principles of convection. 

A certain enthusiasm has been created in the idea that water heated 
from the earth possessed superior curative qualities. It is claimed, and 
correctly, that some such waters contain radium or some other radio¬ 
active substance, but, so far as known, not in sufficient degrees to produce 
therapeutic results. The virtue of natural hot baths probably is not so 


APPAKATUS 


361 



great as the public is often led to believe, for the real virtue of beat 
need not be sought at far-away points except to indulge the fastidious 
taste or for psychological effects. 

Under systematic management, 
the same physical effects can be 
derived at any properly managed 
hydropathic institution, sanita¬ 
rium, or, often, even in the home. 


APPARATUS 


Ultraviolet Rays. —The ap¬ 
paratus employed for the admin¬ 
istration of radiant light and 
heat and the high-frequency cur¬ 
rent has been developed or im¬ 
proved until at the present time 
the more exact knowledge of 
their requirements, indications, 
and methods of employment seem 
to have reached standards ap¬ 
proaching perfection. 

The introduction by Neils 
Finsen of the electric arc for the 
development of ultraviolet rays, 
in the treatment of the forms of 
lupus, marked the earliest type 
of apparatus introduced, types 
now superseded by the air- 
cooled and water-cooled ultra¬ 
violet lamps of the Cooper 
Hewitt mercury vapor type. 

Hofmann Quartz Carbon Arc 
Lamp (Fig. 1).—A study of 
the refinements of the quartz 
carbon arc lamp, introduced by 
Emil Hofmann, Ph.D., M.E., 
reveals that the carbon pencils 
which burn in a semivacuum per- Fig. 1.—Quartz Carbon Arc Lamp. 
mit an increase of voltage and (Hofmann.) 

decrease of amperage, which re¬ 
sult in a 2-inch crescent unusually rich in ultraviolet radiations of higher 
frequency. 













362 


THERMOTHERAPY 


The radiant energy emerging through the quartz globe includes all 
wave-lengths from the infra-red to the ultraviolet of 2,320 Angstrom units 
(232 millimicrons) inclusive. With the semiquartz globe furnished, the 
spectrum emitted includes all the wave-lengths from the infra-red 
through the entire visible spectrum to the ultraviolet of 2,900 Angstrom 
units (290 millimicrons) inclusive. As these globes are interchangeable, 
a convenient means is provided for the selection of ultraviolet wave- 

lengths to suit a given condition. At 
the same time the entire visible spec¬ 
trum is available and also the infra¬ 
red. 

The quartz carbon arc operates 
on 110 or 220 volts with either alter¬ 
nating or direct current and uses 10 
amperes of current. 

Uniform quality of radiation is 
secured by the use of a sensitive 
electromechanical device which auto¬ 
matically maintains a luminous cres¬ 
cent of constant length. 

The original carbon arc, as used 
by Finsen, was an open arc with a 
short crescent and poisonous gases 
produced had to be conducted to the 
open. This lamp gives an abundance 
of the shorter irritating ultraviolet 
rays, and at the same time long, or 
mild ultraviolet, together with a con¬ 
tinuous spectrum, equal to the sun 
and the infra-red rays with a mild, 
pleasant thermic radiation. This 
phenomenon prevents excessive burn¬ 
ing in time exposure. 

Lortet and Genoud later intro¬ 
duced a lamp for the same purpose, 
the London Hospital lamp, which consisted of an arc light constructed 
to reflect its rays through two rock crystal plane lenses placed on either 
side of a chamber, through which water was flowing to maintain a tem¬ 
perature which would permit pressure against the bare skin without 
giving discomfort to the patient. In this manner it was possible to render 
the skin anemic and so permit the penetration of the ultraviolet rays 
more deeply into involved areas. The X-ray later largely displaced the 
latter type in the treatment of infections of the skin. 

The later invention of the mercury vapor lamp by Cooper Hewitt, 



Fig. 2.—Air-cooled Mercury Vapor 
Lamp. 







APPARATUS 


363 


of New York, and the adoption of the quartz tube by Dr. Kromayer, of 
Vienna, introduced an apparatus which permits the passage of the ultra¬ 
violet rays. These lamps, both air-cooled and water-cooled, afford a more 
potent means of administering the ultraviolet rays with greater numbers 
of these rays and devoid of the orange, red and heat rays. These lamps 
now fill an important place in the therapeutics of infections and produce 
other effects upon the blood and metabolism (Figs. 2 and 3). 

During the closing years of the nineteenth century, Dr. Margaret A. 
Cleaves, of New York, introduced 
the use of the marine searchlight as 
a therapeutic means of administering 
radiant energy of high and varying 
candle power. The radiations re¬ 
flected. from iron-cored carbon elec¬ 
trodes are rich in all of the rays of 
the solar spectrum important in 
therapeutics. She also introduced 
the use of the arc-light hath which 
was advocated in the treatment of 
tuberculosis. 

Minin, a Russian physician, who 
advocated the use of reflected light, 
passed through a natural blue glass 
bulb or plate, for relief from pain, 
introduced about this time the Minin 
lamp. This form of administration 
has been variously reputed to possess 
marked therapeutic analgesic effects, 
perhaps largely due to the increased 
reflected heat generated in the glass 
bulb, which becomes intensely hot 
from the absorption of the other vis¬ 
ible and infra-red rays. Some au¬ 
thorities, however, still maintain that there is an analgesic effect derived 
from the blue rays, which the author has been unable to confirm. 

Incandescent Light. —Incandescent high-candle-power lamps were in¬ 
troduced to the profession in 1904 in the form of the so-called “leucodes- 
cent lamp.” This apparatus was widely advertised and exploited, which 
was undoubtedly instrumental in calling attention to the value of intense 
reflected incandescent light radiations. 

The idea that candle power contributes to penetration has been largely 
derived from the introduction of this form of apparatus; whereas the 
candle power of radiant energy has nothing to do with the penetration, 
but rather with the intensification of the penetration, which is limited 








364 


THERMOTHERAPY 


by the surface toleration of the skin of the patient to the heat. By the 
use of intense forms of incandescent radiation, from which the ultra¬ 
violet rays are eliminated by passage through glass, the thermic and 
luminous effects of radiant energy have been thoroughly investigated and 
their value as therapeutic measures verified. 



Fig. 4.—Reclining Body Light Bath. 


At about the time that the high-candle-power lamps were exploited, 
Hr. Kellogg at the Battle Creek Sanitarium introduced the incandes¬ 
cent light cabinet baths and became an ardent advocate of sunlight baths 
in the nude state. 

Light baths have gone through a period of evolution and change, until 
now a high state of perfection has been attained both in point of construc¬ 
tion and efficiency. The introduction of ventilation of this form of 
bath, by the suggestion of Dr. Titus, has been recognized as important, 
in order to allow the escape and change of air during the administration 





APPARATUS 


365 


of the cabinet bath, so as to carry away the moisture and other emanations 
and provide a steady influx of fresh air (Fig. 4). 



Fig. 5.—Illustrating the Law of Reflection—The Angle of Incidence Equals 
the Angle of Reflection. 

Small Therapeutic Lamps and Applicators. —In the writer’s work, 
Radiant Light and Heat and Convective Heat , and in the first edition 



Fig. 6.—Reflection from a Parabola. This shows the relative position of the light 
to the reflector as producing convergent, parallel, or divergent rays in conformity 
with the law of reflection. 


of Therapeusis of Internal Diseases he called attention to the importance 
of reflecting the light rays in parallel or in slightly divergent beams 



Fig. 7.—Incidence of a Focus with the Dark Spot Beyond the Focal Point. A 
circle indicates the dark field at a far point. 


(Figs. 5, 6 and 7). The necessity for this was suggested by the fact, 
that many lamps on the market reflected a focus at a short distance from 
the lamp and so rendered impossible its therapeutic employment unless 










366 


THERMOTHEKAPY 



Fig. 8.—Small Hand Lamp Project¬ 
ing Parallel or Slightly Diver¬ 
gent Rays. 


the manufacture of a type of appa¬ 
ratus that had been introduced in 
the Woman’s Hospital in Hew 
York City by Dr. Herman Grad. 
The first lights manufactured were 
employed for warming up the 
bodies and limbs of the young vic¬ 
tims of poliomyelitis, the treatment 
of whom, at the request of Dr. Regi¬ 
nald Sayre, was placed under the 
writer’s direction in Bellevue Hos¬ 
pital, Hew York City, following the 
epidemic of 1912. These lamps of 
different form (Figs. 10 and 11) 
were extensively employed in the 
Physiotherapeutic Departments of 
the Government Hospitals during 
and following the late War and 
probably accomplished more toward 
bringing the profession to the rec¬ 
ognition of the value of radiant 
energy in therapeutics than would 
have been otherwise possible. 

An error in the terminology of 
this form of treatment, “baking,” 
was instituted at this time. Ho 
greater error in terminology could 
be made than the employment of 
the term “baking” for this form of 


rapidly moved over the surface. A 
lamp of suitable type has now been 
perfected (Figs. 8 and 9). This en¬ 
ables the operator to place the lamp 
in position at a distance at which the 
temperature can be tolerated for requi¬ 
site periods of time.. 

Multiple Light Reflectors. —The 
need in therapeutics for a uniform 
reflection of light over considerable 
surfaces, such as the trunk, resulted in 



Fig. 9.—Larger Lamp of Same Type as 
Fig. 8 with Stand. 









APPARATUS 


367 



treatment, for, as Dr. Byron S. Price has well said, “the term ‘baking’ is 
not only absurd but wholly misleading. ‘Baking’ means cooking and 
necessitates an elevation of temperature in the interior of the substance 
that is being baked to a degree of 160° F. or higher; whereas the body 


Fig. 10. —Smaller Type of Multiple Light Reflector Made Adjustable for 
Convenience in Transport. 

temperature, general or local, probably never exceeds 106° F. under the 
most intensive treatment.” 

The incandescent light bulbs employed in these lamps, as in all thera¬ 
peutic lamps which aim to produce the greatest degree of heat penetra¬ 
tion, are of the carbon filament type, and, as previously stated, the so- 
called “deep therapy lamps” are only so in name, as penetration depends 
upon the quality or richness of the rays in the waves of greater wave- 











368 


THERMOTHERAPY 


length and lower frequency, particularly the infra-red rays, which are far 
more abundant as produced from the carbon filament incandescent bulbs. 

An adjustable form of in¬ 
candescent lamp, reflecting par¬ 
allel or slightly divergent rays 
and of moderate cost, is the 
lamp shown in Figs. 8 and 9 on 
page 366. 

Dry-hot-air Apparatus.— 

Dry-hot-air apparatus is used to 
administer dry-hot-air and is 
constructed for gas and electri¬ 
cal heating, and for limb and 
body applications. 

Body Type .—The body type 
of apparatus (Fig. 12) can be 
used only by institutions, and 
is better heated by gas Bunsen 
burners than by electricity. A 
properly constructed apparatus should be provided with means for 
opening it and pushing the patient into the opened receptacle or should 



Fig. 11. —Largeb Type of Multiple Light 
Reflector. 



Fig. 12.—Gas-heated Body Dry-hot-air Apparatus. 

open over the reclining table. The heat should be furnished through a 
gas pipe at least one inch in diameter, in order that it may be possible 



























APPARATUS 


369 

to insure adequate pressure to raise the temperature to 500° F. Turkish 
toweling wrappings and gowns are essential parts of the equipment. Ex¬ 
perience has shown that there should be an upright shield of wood provided 
to prevent the overheating of the patient’s feet. It is possible that a 



Fig. 13. —Dry-hot-air Apparatus for Administration of Heat to Leg or Arm. 


body apparatus could he constructed to supply heat by electricity, hut 
this is a slower method of getting up the requisite heat, and requires 
expensive resistance coils for heating, in order to supply the requisite 
500° F. 

Extremities Type .—For local applicators for the extremities (Fig. 13), 
the gas apparatus is practical and costs far less than the electrical heating 

























370 THERMOTHERAPY 

devices and is less expensive to operate. To meet every demand an 
apparatus open at both ends for applying heat to the knee-joint (Fig. 14) 
has been made by the manufacturers. This apparatus is only of value 
to those who have not the more effective facilities for treating arthritis 
by diathermy or the static currents. 


Fig. 14. —The Gas-heated Dry-hot-air Apparatus for Treating the Knee or 

Elbow Joint. 

Hydrotherapeutic Apparatus.— The facilities for administering 
whirlpool baths and cold and hot packs are the more practical types of 
apparatus required for hydrotherapy adminstrations. 

The whirlpool bath, which was designed and perfected in the hos¬ 
pitals during the Great War, has filled a useful role as a means of pro¬ 
ducing a peculiar water massage to inflamed tissues. The value of 
this apparatus has been greatly enhanced by Dr. Bardwell’s design. The 
bath should be made of Monell metal, which does not require painting 
or finishing. This should be made in the original form, whereby the 











APPARATUS 


371 



Fig. 15.— The Whirlpool Bath. (Courtesy Dr. Bardwell.) 

jets are applied with pressure to the body. A very active superficial 
hyperemia of the tissues of the skin is the result, but this may often 
be as well or better obtained by the employment of body administrations 
of radiant light and heat. In the treatment of the spinal cord or other 
conditions of the nervous system it cannot be compared in efficiency with 
the static current. 

High-frequency Apparatus. —The earliest type of high-frequency ap¬ 
paratus designed by d’Arsonval consisted of a Ruhmkorff coil attached 


water is thrown into stronger commotion, effecting a greater degree of 
mechanical effect to parts under treatment (Figs. 15 and 16) than the 
earlier type of apparatus. 

Apparatus for giving douches and jet sprays is employed in institu¬ 
tions, its principal effect being to produce skin reaction as hot or cold 














372 


THERMOTHERAPY 



Fig. 16.—Arrangement for Producing the Agitation of the Water in the Whirl¬ 
pool Baths. (Courtesy Dr. Bardwell.) 


1 



Fig. 17.—Complete Coil Equipment for High-frequency and X-ray Apparatus 
of the d’Arsonval Type. —A, line-switch; B, interrupter; C, rheostat; D, Ruhmkorff 
coil; E, Leyden jar condensers; F, high frequency solenoid; G1 and G2, d’Arsonval 
terminals; SGj high frequency spark gap; M, meter. 























































































































APPARATUS 373 

to a resonator for transforming the high voltage current of the coil to the 
high-frequency current (Fig. 17 ). 

The resonator consisted of two condensers, either Leyden jars or other 
condensers, in which tin foil was insulated between layers of insulating 
material. A solenoid or coil connected the outer coatings of the jars, or 
a corresponding arrangement was made if other types of condensers were 
used. A spark gap which might be varied in length, single or multiple, 
was placed between connections between the two inner coatings. The 
jars, solenoid, and spark gap, being arranged in series with the inner 
coatings of the condensers, were connected with the source of the current 
on either side. A solenoid or coil connected the inner coatings (Fig. 18 ). 



Fig. 18. —Arrangement of Condensers, Spark Gap and Solenoid. This shows 
arrangement with patient in circuit. 


The same principle as concerns the resonator is employed with all modern 
types of apparatus hut with greatly improved facilities. 

Modem Types .—Modern types of apparatus used for the production 
of high-frequency currents employ the alternating current and consist 
of a large capacity oil-immersed transformer in which the primary and 
secondary are wound upon two parallel bars insulated from each other. 
The primary wire receives the current from the A.C. commercial current, 
or the direct current transformed to alternating by a rotary-converter. 
Insulated wire is wound in relatively few turns around the primary, 
and very fine insulated wire in the secondary is provided with the requisite 
number of windings or turns and fineness to give the necessary induc¬ 
tance and impedance to produce the desired potential or voltage of the 
apparatus. The current thus transformed is conducted into the resonator. 
In the construction of these transformers attention is required by the 
manufacturers to adjust the windings and condensers to a true resonance, 











374 THERMOTHERAPY 

for a correct attunement is essential to the delivery of a proper thera¬ 
peutic current. 

The spark gap of the resonator is one of the most important essentials 
to a perfectly working apparatus. The multiple spark gap should be pro¬ 
vided with a number of discharging points and a device by which the 
length of these gaps may be varied, increasing or diminishing the resist¬ 
ance in the patient’s circuit (Fig. 19) to the requirements of the heat 
desired, and indicated by a hot-wire meter in series. The best types 
of interrupters are those in which the multiple gaps are all opened to¬ 
gether, instead of increasing the number or length of the gaps. The tips 
of such interrupters should be made of tungsten, a metal capable of with¬ 
standing long usage. 



Fig. 19. —Modern Type of Multiple Spark Gap Interrupter Regulated by Increas¬ 
ing the Spark Length with All of the Gaps Constantly in Circuit. 


If these gaps discharge in the open by a method which opens all the 
gaps at one time, the oscillations will be more perfect and uniform than 
by other methods. Furthermore, the wear upon all the tips is the same, 
and the variations regulated by opening or closing all the gaps is uniform, 
an improvement over many types of apparatus. 

Cross sparkings in the spark gap produce a noisy, unharmonious dis¬ 
charge, and a lower frequency, in point of the oscillations, than the gaps 
described. 

The objections to a closed gap are: (1) that it must be frequently 
opened and cleaned, otherwise the discharge soon becomes imperfect, and 
(2) those with mica-insulating discs often become punctured, requiring 
that they be replaced. 

The capacity of the condensers in the alternating current circuit is 
varied to give the desired amplitude and frequency. Two to four con¬ 
densers of one quart capacity, coated, if Leyden jars, within and without 
over about two-thirds of the surface, is the usual arrangement in the 




APPARATUS 375 

modem types of apparatus, and of an equal capacity in the closed 
condensers. 

The Oudin terminal of a resonator is an additional requisite. An 
attachment to one terminal of the d’Arsonval circuit is made, consisting 
of a coil of the Guilliminot type; that is, the windings are arranged 
from the center to the periphery or vice versa, and they are of a sufficient 
number of turns to give a three to five-inch discharge from the Oudin 
terminal. This attachment is used for administering discharges of higher 
voltage than from the d’Arsonval terminals, and should be constructed 
with adjustments to give a range of varying discharges from the cold 
spark, which will not ignite parchment paper to a heavier fulguration 
or burning spark. The latter is applied for administering currents with 
vacuum or non-vacuum electrodes and the hot fulguration spark, while 
the former discharge is used for administering the desiccation spark for 
the removal of condylomata epitheliomas, keratoses and lupus patches. 

Electrodes for Special Applications. —A large variety of electrodes 
has been designed for special applications ; non-vacuum or vacuum elec¬ 
trodes adaptable to the various cavities of the body, as well as electrodes 
for surface treatment. Electrodes for administering diathermy currents 
are best made of composition metal of a gage that will not crumple, but 
that will remain relatively smooth—in thickness approximately twenty- 
two B. and S. gage. The same material is used for other electrodes. These 
are made in different shapes, usually rectangular with rounded comers, 
and are adapted for applications to varying surfaces and conditions. The 
edge is rolled up or evenly rounded, so that there will be no discharge of 
fine sparks or sprays from rough edges or angles, which would give annoy¬ 
ance to the patient and make the administration impossible. These include 
the more practical types of metal surface electrodes, which can be prepared 
and used in individual cases as required by the operator. 

Disc electrodes provided with handles are furnished by manufacturers, 
but these are not readily applicable, for it is not convenient for the patient 
or operator to hold them in place during the long applications which are 
necessary for the relief required. 

The clips and cords for transference of the current, and holding the 
electrodes are of importance. The cords should be made of flexible or 
braided wire, which will not become angulated and break, because a break 
in the circuit of a cord will give a very disagreeable shock to a patient. 
Each apparatus should also be provided with one or two bifurcated cords 
for two attachments to the patient’s end; so that two electrodes can be 
connected from one side of the d’Arsonval circuit in administering appli¬ 
cations to two surfaces from one pole, with a large indifferent electrode 
placed at a definite place to complete the circuit from these surfaces. 

The clips attached to the end of the connecting cords should be pro¬ 
vided with slots, into which may be slipped the edge of the electrodes. 


376 


THERMOTHERAPY 


One extremity should consist of an open jaw provided with a screw for 
clamping it to the electrode. The clips should be capable of being se¬ 
curely held to the electrode, so that it will not become displaced during 
the process of treatment, when it might severely burn the patient. 

Another measure to be provided is a means for securing the electrodes 
in position, so that a restless or nervous patient cannot remove them 
during the passage of the current, and so occasion a disagreeable burn 
from a small contact during the treatment by an attempt to remove the 
electrode when a current is passing. Pads with straps and buckles or 
bandages, which can be secured by the operator, are suitable devices for 
securing the electrodes in position. Such is a practical precaution against 
accidents in case of such patients. 

Autocondensation. —The autocondensation couch or chair is one of 
the perquisites of thermic treatment. The couch or chair (Fig. 20) 
should he of such length that the patient’s body and extremities can be 
placed in a field opposed to a sheet of metal or wire mesh measuring 
approximately sixteen inches in width by sixty inches in length and 
provided with a socket for connecting one pole of the d’Arsonval terminal 
to the sheet of metal. Over this should be placed a felt or silk-lined 
cushion, approximately three inches in thickness and six inches wider 
and longer than the sheet of metal. The cushion may he covered with 
leather, cloth material, or pantasote. Upon this the patient should re¬ 
cline during the administration of the autocondensation current, and it 
may be employed either for administering the treatment for hypertension, 
or in the indirect d’Arsonval method of treatment for heat therapy to 
he described. 

A large solenoid for autoconduction treatment, as devised by d’Arson- 
val, should he approximately two and one-half to three feet in diameter 
and six feet in height when extended, and consists of a spiral coil of wire, 
the opposite extremities of which are connected to the opposite terminals 
of the d’Arsonval solenoid. This apparatus is not often used in this 
country and would be rarely called for, because the autocondensation 
method is far more practical and accomplishes all or more than could 
be accomplished by the large solenoid. 


GENERAL PRINCIPLES OF TECHNIC IN THERMOTHERAPY 

Certain general principles apply to all methods of employing heat in 
therapeutics: (1) the surface treated should always he considerably larger 
than the parts involved in the pathological process; (2) when stasis is 
established, heat may increase it, whereas, before stasis is established, 
heat thoroughly applied—preferably by the conversive methods—may 
prevent it; (3) the effects of the high-frequency vacuum and non-vacuum 


RADIANT LIGHT AND HEAT APPLICATIONS 377 


electrodes and effluves, as measures for inducing heat locally, are limited 
by the surface irritation produced. The counterirritant action of the cur¬ 
rent by these methods induces a very active superficial hyperemia, and 
the effects are like those of conversive heat, the current passing in and 
out of the body—at capacity. 

The technic of the methods for producing conversive heat, radiant 
light and heat, and diathermy is distinctly variable according to the 
effects sought. 

Skin Toleration. —In all methods of heat application, there are prac¬ 
tical rules of limitation to the degree of heat applied that will vary ma¬ 
terially with different methods. The skin will stand a greater degree 
of heat from dry hot air than from any other method of application, and 
paraffin baths are tolerated at a temperature far greater than warm water. 
The surface is peculiarly sensitive to moist applications or applications 
that produce moisture that cannot be promptly absorbed or evaporated. 

Time of Application. —With all methods the indication is to alter 
local conditions, requiring as a rule prolonged applications of conversive 
heat in order that the fixed cells may become well heated, that the cooling 
influence of the blood-stream at normal temperature may not too rapidly 
restore to normal the heated tissues and limit the duration of the hyper¬ 
emia, which, for beneficial effects, should persist for a considerable time 
after the administration. 


TECHNIC OF RADIANT LIGHT AND HEAT APPLICATIONS 

Position. —The position of the patient should, as a rule, he reclining 
and comfortable, and the source of the rays should be so placed that the 
radiations will be projected perpendicularly upon the surface requiring 
treatment. 

Distance. —The distance from the reflecting source of light should be 
adjusted to the comfort of the patient with a degree of heat always verging 
on discomfort—very warm. 

Extent of Exposure. —The extent of exposure, as previously stated, 
should be decidedly larger than the area, of involvement, but should be so 
limited as not to cause discomfort from relatively heating unnecessarily 
parts not requiring it. This may usually be regulated by the use of a small 
light apparatus for a small area and larger lamps or applicators over the 
body and extensive surface regions. 

Length of Exposure. —The time required should be in nearly all con¬ 
ditions, wdien not otherwise specified, at least one hour for each adminis¬ 
tration. In cases of severe conditions, as of erysipelas or abscesses, the 
one-hour exposures should be frequently repeated or continuous, and con¬ 
tinued until severe symptoms have subsided. 


378 


THERMOTHERAPY 


Large Applicators. —Large applicators with multiple lights within 
a reflecting surface are used for their tonic and constitutional effects, 
and the treatment should not be continued until they cause a feeling of 
exhaustion. One-half-hour applications are, as a rule, sufficient. 

Light Baths. —These baths should he administered, except in sturdy 
individuals, with the patient in a reclining position and followed by a 
considerable period of rest after the administration. The temperature 
of the bath should be such as not to cause discomfort to the patient and 
the time ordinarily not longer than twenty minutes. 


TECHNIC OF THE OVEN BATH 

Ho treatment should be administered during the period of active diges¬ 
tion or while under excitement. The room in which the treatment is 
given should be well ventilated and should be at a comfortable tempera¬ 
ture at the time when the patient is being transferred, when all draughts 
must be avoided. 

The administration should take place with the patient lying in position 
upon the oven table. The oven table should be perforated and provided 
with a mattress about one inch in thickness for the comfort of the patient, 
and to protect against burning. The patient should be covered with three 
thicknesses of Turkish toweling tucked in around the extremities or 
angular parts of the body. Additional thicknesses of toweling should 
be applied over the feet and legs, and, if the patient is corpulent, another 
thickness over the abdomen. These wrappings should be without folds 
and applied without undue pressure anywhere, and the bath sheet should 
be tucked in under the mattress edge; otherwise some of the heat will 
escape. The oven table is then pushed into the oven and the heat retaining 
curtain is placed around the patient’s neck and shoulders, in order that 
the hot air may not escape. The gas is then lighted and the oven tem¬ 
perature should rise to from 400° to 450° F. within four minutes. A 
lower oven temperature and less covering does not give the same result. 
During the administration and also after being placed in bed, the pa¬ 
tient’s head must be constantly cooled with frequent local applications 
of cold damp cloths. 

When the body is exposed to high temperatures and the head is 
kept cooled, a secondary dilatation of the intracranial vessels will be pre¬ 
vented and the following evidence of the reflex effect will be produced. 

“Shortly there is a marked reflex stimulation [in every case]. This state 
of stimulation is accompanied by mental exhilaration and clarity of 
thought. The pulse becomes slower, fuller, and relatively strong in cases 
of cardiac dilatation or toxicity in which there was previously a rapid, 


TECHNIC OF THE OVEN BATH 379 

weak, irregular or thready pulse. Preexisting cyanosis gradually 
disappears. 

“In from ten to thirty minutes after the beginning of treatment, and 
dependent chiefly upon his reflexes, the patient’s pulse becomes softer, 
when previously hard. Bather quickly there is established a distinct sen¬ 
sation of . a full, soft, rolling pulse, often with prolonged diastolic and 
full systolic periods, apparently in part due to the diversion of the blood 
to the arterioles, whose elasticity is increased by the heat, hut also to 
neuromuscular stimulation. The quality of the pulse is characteristic, 
once one is familiar with it. 

“If, however, the body has been exposed to a temperature much lower 
than 400° F. no such effect occurs, hut after a considerable length of 
time, there is, instead of stimulation, an actual depression, accompanied 
by mental inactivity and a general sense of laxity proportionate to the 
length of time the patient is exposed to the heat. Such effect from slow 
and low heat application neutralizes all attempts at producing reflex stimu¬ 
lation, later, by rapid and high temperature applications. 

“Under these latter incorrect conditions a patient suffiering from car¬ 
diac dilatation or toxicity shows little tendency towards improvement in 
the quality of pulse at any time, and, if long continued, there is still 
further evidence of depression and increasing cyanosis.” 

In order to note the heat effect produced upon the deep glandular 
areas Dr. Price has found that it was necessary “to continue the heat 
application until the peak of nervous stimulation has been passed with a 
tendency to drowsiness, else the patient is left in an uncomfortably over- 
stimulated nervous state without the full accomplishment of the main 
object, glandular stimulation. This period also corresponds with that of 
the fully developed and characteristic pulse quality. 

“The patient’s temperature is no index to sufficient dosage, and, if it 
were, an accurate reading could not he obtained by mouth because of the 
cold applications. Even the rectal temperature does not increase much over 
2° F. under usual conditions. Therefore, the result obtained is impossible 
of explanation from the penetration of heat. It is a reflex result.” 

During this time the patient is always kept incased in Turkish towel¬ 
ing, and cold applications applied locally to the head. The room should 
be kept at a temperature not lower than 75° F. for a period of five to 
fifteen minutes during which time the water temperature is lowered 
somewhat. 

“Immediately upon the establishment of a complete reaction the 
patient should be transferred from the oven table to the lowering device, 
which is in readiness over the bathtub full of water beside the oven table. 
This water must be at a temperature of from 107° F. to 109° F., depend¬ 
ing upon the patient. 


380 


THERMOTHERAPY 


“After a period of five to fifteen minutes, during which time the water 
temperature is lowered somewhat, the pulse diminishes slightly in fre¬ 
quency and loses some of the. characteristic rolling quality. At this 
time the patient should be raised out of the water on the tub elevator 
and, under the Turkish toweling, given a rapid rub with hot salt all 
over the body. It is imperative to avoid the contact of air currents, even 
for an instant, as they cause peripheral arterial contact with correspond¬ 
ing splanchnic dilatation.” 

After the salt rub the patient is again immersed, to wash off the salt, 
and then raised out of the water and covered with a hot dry bath sheet, 
replacing the wet one. The patient must always be kept in the prone 
position, and is not allowed to sit upright for danger of syncope. The 
blood at this time has been drawn from the interior to the surface, and 
it may be said in this connection that the skin will contain two-thirds 
of the blood of the body; for this reason great care should be taken in 
all the movements of the patient that he be lifted and maintained in a 
reclining position. 

After removal to the table he is thoroughly dried and massaged, and 
is allowed nothing to eat or drink except hot water, if thirsty, for a 
period of two or three hours or more, depending upon the condition, during 
which period he is not allowed to change from a horizontal position; or 
he might suffer an attack of syncope, from the presence of so much blood at 
the surface. 

“After a period of five to seven hours, except where especially contra¬ 
indicated, the patient may assume his usual course. It is necessary to 
remain quiet for this period, as such is required for the natural and 
complete restoration of responsiveness on the part of the heart muscle, 
as well as that of vasomotor control. In persons with cardiovascular 
disease there is serious danger in getting around earlier. If such a person 
rises too early after the treatment, there is splanchnic dilatation, in 
degree depending upon conditions, but in all cases the early assuming 
of the upright position obviously disturbs the channels of vascular dilata¬ 
tion as produced by the heat, with the consequence that the glandular 
activity already established is terminated. 

“After a properly managed oven bath in cases of submetabolism there 
is found in the following twenty-four-hour sample of urine a marked 
increase in the total solids over the preceding sample, whether the de¬ 
ficiency was in urea or chlorids, elimination arising from acidosis, intes¬ 
tinal toxemia, or in the blood retention of sugar. The blood analysis 
correspondingly shows a diminution in urea, chlorids, sugar, or acetone 
bodies. This result is so pronounced that such cases, when apparently 
hopeless, do revive because of the stimulation of the deep reflexes and the 
prompt elimination.” 


TECHNIC FOR ADMINISTERING HYDROTHERAPY 381 


Local Hot-air Baths. —The local hot-air hath is indicated for the treat¬ 
ment of local septic infection in an arm or leg where stasis and edema 
are not too marked or where pus, if present in the subcutaneous tissues, 
has been evacuated. The parts should be wrapped in at least three or 
four thicknesses of Turkish toweling and placed in a small oven designed 
for the purpose, upon the suspension device provided in the apparatus, 
and with the heat-retaining curtain carefully adjusted so that no heat 
will escape; the heat is then turned on. 


TECHNIC FOR ADMINISTERING HYDROTHERAPY 

The technic for administering hydrotherapy according to Baruch is 
as follows: 

The Wet Pack. —“T 'wo large woolen blankets are spread upon a mat¬ 
tress, most appropriately placed (a rubber sheet must intervene to protect 
it from the moisture) upon a high four-legged cot. Upon this is spread 
smoothly a linen sheet, wrung out of water of temperature 60° to 70° E., 
appropriate to the case; the blanket should be long enough to extend 
a foot or more beyond the patient’s extremities. The patient is placed 
upon the sheet, with his arms raised alongside the head. One-third of 
the sheet is drawn from left to right across the chest. The arms are low¬ 
ered alongside the body and the other two-thirds of the sheet are brought 
across the body, covering both arms but leaving the latter separated 
from the trunk by the intervening sheet. The lower part of the latter 
is pressed between the thighs and legs and the lower border tucked under 
the heels. The upper border of the blanket is now grasped with the 
right hand, drawn at right angles to the clavicle downward, the fingers of 
the left hand are placed about fifteen inches from the clavicle against the 
border of this tightly drawn portion and held there while the right hand 
draws and pushes the latter across the chest over the clavicle and shoulder 
beneath which it is tucked. This procedure is similar to reversing a 
bandage. Then on both sides the blanket is brought over the body and 
tightly tucked under it; then drawing with the left hand upon the por¬ 
tion of the blanket or sheet covering the patient, then with the outstretched 
fingers of the right hand pushing the border of the blanket covering the 
body beneath the latter along the entire length of the body. This pro¬ 
cedure is repeated on the other side, with the second blanket. The lower 
edge of the blanket is now gathered together and tucked beneath the 
heels. Everything depends upon complete exclusion of air from the 
blanket cover. The patient may now be covered with more woolen blankets 
if necessary. If the covering has been skillfully done the patient will 
resemble a mummy whose head is enveloped in a wet turban. Unless 


382 


THERMOTHERAPY 


given for insomnia the patient should receive an affusion at 70° E. after 
removal from the wet pack and go into the open air after being dried. 

“Modification of this procedure consists in half packs, in which smaller 
or larger parts of the body are enveloped in the damp sheet. The duration 
of the pack (which should be from one-half to one hour), the texture of the 
sheet, the temperature of the water and extent of pack, as well as the repe¬ 
titions, modify the effect materially, as will be seen. If given for insom¬ 
nia, the patient must remain in the pack, if asleep; rapid but gentle drying 
follows, and the pack must be given in the bed.” 

Dr. Baruch further states: “The first effect of contact with the cold, 
damp sheet is an irritation to the cutaneous nerves, and narrowing of 
the cutaneous vessels, which continues until the individual’s power of 
reaction comes into play. This depends, as in all hydriatic procedures, 
upon the age and condition of the patient; old people and children do not 
react as readily as adults, and a previous high temperature of the skin 
furthers rapid reaction when circulation is not very feeble. There being 
no mechanical aid given by the attendant, as in the sheet-bath, reaction 
depends entirely upon the vital powers of the patient. This fact dis¬ 
tinguishes the wet pack completely from all other hydriatic procedures, 
and demands judicious recognition of the patient’s reactive capacity. As 
soon as the first “shock” is over, which lasts one to five minutes and some¬ 
times produces shivering, the peripheral vessels begin to dilate, and the 
system makes an effort to equalize the temperature between the skin and 
the sheet. When the body temperature is high, as in fevers, there is no 
chilliness, the cooled blood is driven from the surface to the subjacent 
structures, but very soon the warm blood from the interior takes its place, 
and dilatation of the vessels is the result. This continuous interchange 
of temperature, which occurs easily and slowly in patients with normal 
temperature, gives rise to a vaporization of the sheet which furthers loss 
of heat from the skin. This is increased by non-conductivity of the blanket. 
He soon experiences a mild heating of the body due to the conservative 
powers of the organism, continuing to create heat to compensate for the 
threatened or accomplished loss.” 

The Whirlpool Bath. —This bath, introduced during the Great War 
for use in the Army, serves as a valuable means of treating open wounds 
and inflammatory conditions. It was found particularly valuable in the 
treatment of tender stumps. The parts should be immersed for a con¬ 
siderable time during each administration. 

The discharge of water through a one-eighth-inch opening under pres¬ 
sure as in the Bardwell type of bath (Figs. 15 and 16) draws in the air, 
giving a greater degree of commotion in the tank than did the first appa¬ 
ratus used in the Government Hospitals. 


THERAPEUTICS OF HEAT 


383 


The aerator designed by Dr. Bardwell differs distinctively in the 
nozzle, which may be attached to any tank, of which there were and are 
now many forms employed in the Army Hospitals and in the Veteran’s 
clinics. 

The apparatus is best made attached to the tank, as a permanent 
fixture, with provision for the drain overflow. The Leonard mixing valve 
and air meter should he directly attached to the tank as any two faucets 
on a sink. 

This apparatus is used very extensively in the Veteran’s Bureau 
Hospitals throughout the country, and serves a useful purpose as one of 
the measures that are employed for relieving some of the less common 
painful conditions. 


THERAPEUTICS OF HEAT 

Heat Therapy. —This subject embraces a very extensive field of indi¬ 
cations. It fills a very important role in the treatment of a large range 
of impaired conditions of function and inflammation. There is undoubt¬ 
edly no measure in medical use that so aptly or completely fills the useful 
demand for the treatment of infectious conditions as the methods of em¬ 
ploying convective and conversive heat. Likewise, in the treatment of 
defective metabolism impaired by inflammation and disturbed functions, 
these measures are used in conjunction with other physical modalities 
and accomplish results that are not and cannot he obtained by other 
measures in medical practice. 

The application of radiant light and heat, dry-hot-air, and diathermy 
to the treatment of local infection , as previously stated in explaining the 
physiological effects of hyperemia, acts upon infectious conditions in three 
distinct ways: 

1. The application of heat and light is particularly efficacious in 
destroying certain bacteria in situ. All bacteria in superficial fields sus¬ 
ceptible to light or 106° F. of heat may be destroyed by applications of 
radiant light and heat from incandescent sources. In the administration 
of reflected incandescent light and heat, the limit of the temperature 
to be employed will depend upon the skin toleration; and so also, in the 
cavities of the body, conditions that are susceptible to heat, as the pres¬ 
ence of gonococci, yield to applications of diathermy. 

The skin and tissues, as previously stated, will readily withstand the 
ultraviolet ray's, and all bacteria located in or immediately beneath the 
surface are destroyed. This property renders them invaluable in the 
treatment of a large range of infectious conditions. 

2. Another method of effecting the destruction of bacteria is by the 
institution of active hyperemia through heating of the involved tissues. 


384 


THERMOTHERAPY 


By this means the phagocytes are drawn in greater numbers into the 
infected field, raising the local resistance of the tissues and thereby 
enabling the phagocytes to destroy the bacteria, and the tissues to throw 
off the local invaders. The altered condition of nutrition, furthermore, 
gives added force to the fixed cells, the macrophages, in the lymphatic 
system, whereby resistance is fortified against infection and the system 
is enabled to throw off bacterial invaders. 

3. Another method of effecting a local process of infection is by the 
use of the X-ray or radium, whereby the bacteria are sterilized and so 
rendered inert. After a requisite series of short exposures, an active 
hyperemia is induced, as by the previous method, so carrying away the 
inert bacteria. The success of this method is practically demonstrated 
in tubercular and pyogenic processes. 

Treatment of Special Conditions of Infection 

Boils. —In boils prolonged applications of radiant light and heat, or 
prolonged applications of the high-frequency current from vacuum or non¬ 
vacuum electrodes, will often abort the process. This is accomplished 
by the induction of active hyperemia and the action of the heat upon the 
bacteria. 

Abscesses. —Ultraviolet rays have proved very efficacious in curing 
incipient abscesses when applied through a quartz applicator with com¬ 
pression of the offending process. That such an application may produce 
a blister should not forestall a thorough application to the surface, as the 
blister soon disappears and the germ process as well, when treated before 
pus. The same measure may be effective in aborting carbuncles in the 
first stage before pus is formed. The ultraviolet application should be 
followed promptly on the following day by the application of reflected 
incandescent rays with long exposures, which will hasten the healing of 
the blister and further destroy any remaining local infection. 

Another method which has been successful in the treatment of car¬ 
buncles and crops of boils is the administration of an erythema dose of 
X-rays, followed the next day by a two-hour application of reflected ra¬ 
diant incandescent light, and this followed by a thorough application of 
the high-frequency current from vacuum or non-vacuum electrodes. There 
are three factors which enter into this method: (1) thorough sterilization 
—not destruction—of the bacteria by the prolonged application of X-rays; 
(2) active hyperemia, induced by the radiant light and heat, which carries 
in a vast number of phagocytes; and (3) tissue resistance and phagocy¬ 
tosis, which is still further accentuated by the application to the surface 
of the current with the high-frequency electrodes. 

Quinsy. —This may be relieved by the same methods applied externally 
over the indurated tonsil. Another method of treating suppurative ton- 


THERAPEUTICS OF HEAT 


385 


silitis within the first twenty-four hours, confirmed long ago in the writer’s 
experience, is the application of the static wave current with a small metal 
or surface vacuum electrode placed directly over the enlarged hardened 
tonsil, which may thus be softened, with a complete resolution of the in¬ 
duration before pus. There is no danger in the first twenty-four hours, 
before pus, of extending the infection; but the method is effective in 
resolving the process and aborting the tonsilitis. 

Felons and Whitlows. —When these are treated in the first twenty- 
four hours, they may also he promptly relieved by the static method. 
Long exposures to radiant light and heat should precede the use of the 
static current in these cases and also in cases of tonsilitis. Otherwise 
felons and whitlows may be treated with ultraviolet rays and incandescent 
light radiations, as outlined in the treatment of boils and furuncles. 

Acute Otitis Media. —Treatment of this disease by radiant light and 
heat is one of the classical methods in heat therapy that should he univer¬ 
sally adopted, and would be, but for the inattention manifested by the 
otologists. In the first stage of an otitis media, if radiant light and heat 
is thoroughly applied for one or two hours to the surface, at a distance 
at which the patient will tolerate the heat, this procedure will often abort 
the infection at the onset. This the author has confirmed in two instances 
on his own person. If, however, the condition is not aborted, the relief 
afforded by the local applications of reflected incandescent light and heat 
will insure the patient great relief from the intense pain. After the pus 
has begun to discharge, whether a paracentesis is done or not, if the light 
applications are persisted in with two one-hour applications on the first day 
and once or twice daily on subsequent days for at least one hour each time, 
the trouble will be cured with the membrane repaired within two weeks, 
and a chronic discharge will not persist. 

Chronic Purulent Otitis Media. —This can be relieved by daily one- 
hour applications of reflected radiant incandescent light, as in the acute 
cases. This treatment will successfully cure most cases in which there 
is no bone necrosis within three weeks, and usually much sooner, with a 
healing of the membrane. This method was introduced by Herbert E. 
Pitcher, M.P., of Haverhill, Massachusetts, and the writer has observed 
the results from the method in a large number of cases, in none of which 
it took over three weeks to effect a cure. If this statement is doubted, a 
thorough trial and investigation of the method will be convincing. 

Mastoiditis. —Mastoiditis would very rarely occur if otitis media was 
attended to by the method described. It has often been aborted by the 
method outlined above, as reported by Dr. Pitcher in his original paper, 
and this method should be recommended in early cases, notwithstanding 
the attitude of the aurists. If, pending an operation, there was a delay 
for from ten to fifteen hours, a more or less persistent application of 
reflected light over the involved parts has in many cases caused a dis- 


386 


THERMOTHERAPY 


tinct fall in the leukocyte count, indicating that operation was unnecessary. 
Humerous cases of mastoiditis have already been reported as having been 
cured by daring men who were willing to take a chance in the face of 
surgical criticism. There is abundant evidence of the wisdom of such 
a course. We believe that every effort should be made to bring the 
otologist to recognize the importance of employing, in the treatment of 
otitis media, a measure so safe and so certain of success. When this is 
done, mastoiditis will be a rare condition. 

Coryza. —A simple coryza, affecting the mucous membrane of the 
nares, is relieved with remarkable promptness by repeated one-hour appli¬ 
cations of reflected incandescent light, employing the smaller lamp. These 
applications should be made morning and evening, with the lamp sus¬ 
pended at a distance that can easily be tolerated by the skin, so as not to 
cause the patient undue discomfort. If desired, a small pledget of mois¬ 
tened cotton may be put over each eye, but there is no harm from the 
exposure, if the eyes are kept closed during the application. If adminis¬ 
tered morning and evening, rarely more than three or four applications 
will be required completely to relieve the coryza. The same measure 
applied to a throat affected with laryngitis will afford relief. The effect, 
however, is not so uniformly successful as with coryza, hut promptly yields 
to diathermy. 

Sinusitis. —When this is treated by the same method as coryza it will 
require a greater number of applications, but in most cases can be com¬ 
pletely relieved within one month, varying with the condition—acute or 
chronic. This has been a routine practice in the offices of the writer for 
the past fifteen years, and the results have been so uniformly successful 
that he can speak in the highest terms of the results. 

Another beneficial method in these cases is the use of diathermy with 
the active electrode placed over the forehead and sinuses and the in¬ 
different one upon the back of the neck. The active electrode should 
be about two inches in width and six inches long. The relief from dis¬ 
comfort is often instantaneous. 

Suppurative Conditions. —In suppurative conditions of the antrum 
the persistent use of light, after the cavity has been drained through an 
opening into the nares, can be depended upon to dispel the condition, 
which would, otherwise, be persistent. To relieve this condition either in 
sinusitis or in antral abscesses will require several weeks of daily use 
of the radiant incandescent light. 

Purulent Conjunctivitis. —In purulent conjunctivitis of pyogenic 
and gonorrheal origin the radiant incandescent light is remarkably effec¬ 
tive in conferring relief. It is, undoubtedly, the heat in these cases that 
effects the destruction of the bacterial process. From the institution of 
the treatment applications should be made of one hour in duration, each 
followed by a two-hour interval. The relief from pain in the first half 


THERAPEUTICS OF HEAT 387 

hour is remarkable and the progress to a cure usually complete in a few 
days. 

Foreign Bodies.—Following removal of a foreign body from the eye, 
the application of reflected light for half an hour will afford prompt relief 
from the irritation caused by the presence of the foreign body. 

Erysipelas.—There is nothing during recent years that has given the 
writer greater satisfaction than his own results and those of others from 
the use of radiant incandescent light in the treatment of erysipelas. The 
discovery of its efficacy was made by the writer more than ten years ago, 
when a patient came into the office with a well-developed erysipelas 
of the face in the first stage. The light was reflected upon the surface 
for one and one-half hours and the relief was complete, as the condition 
made no further progress. This led to a question as to the diagnosis, but, 
when light was applied later in a very striking and marked case, the same 
result was obtained with a complete cure of the condition within two 
days. It was thus demonstrated that erysipelas can be cured by this 
method, and this has been repeatedly verified. 

Local Septic Infection.—Local septic infection, or blood-poisoning, 
has destroyed the lives of many physicians and surgeons, and frequent 
reports of fatalities establish the condition as a matter of so great concern 
that the management of these cases by heat therapy must be considered 
at length, because we believe it to embrace methods of great importance 
in an otherwise unfortunate class of conditions. 

When, following an accident or operation, the surgeon discovers a 
point of infection, or upon a patient a painful spot appears having the 
characteristic indication of septic infection, the early application of the 
ultraviolet rays over the site, followed by a long application of reflected 
incandescent light and heat, will in nearly all instances abort the trouble. 
In the absence of a mercury vapor lamp there are few cases that will 
not yield to prolonged applications of incandescent radiations from the 
small therapeutic lamp at this early stage. When, however, the infection 
has become seated in the hand or leg, and lymphangitis appears, the 
seriousness of the condition will be confirmed. That there is no difficulty 
in controlling the infection at this stage, either by prolonged applications 
of radiant light and heat, or by the ultraviolet rays, either in cases of this 
kind, or in any case in which pus has not accumulated, is an established 
fact. 

In septic cases which have been opened and drained but in which, from 
peripheral indications, extension to the trunk is to be apprehended, the 
administration of dry-hot-air in the localized oven for treating arms or 
legs promises prompt relief. With the parts well wrapped in three or 
four thicknesses of Turkish toweling, and enclosed in the oven employing 
a temperature of from 400° E. to 500° E. for one hour daily, the heat 
will promptly relieve and cure the condition in three or four days. This 


388 THERMOTHERAPY 

statement is based upon personal experience with a large number of cases, 
without a failure. 

The following case reports will illustrate the method in serious cases 
under varying conditions. There are so many failures under the present 
practice of applying hot wet dressings and the knife, and so many of 
these cases occur, as to lead the writer to urge the investigation of the 
methods outlined. 

Case 1. Mr. S. referred by a local physician came under observation 
after numerous openings had been made draining the pus from the sub¬ 
cutaneous tissues of the arm and forearm. The arm was wrapped in 
Turkish toweling and placed in the local oven apparatus (Fig. 13), ac¬ 
cording to the technic elsewhere described. The treatment was given, as 
is customary, for from thirty to forty minutes with a temperature of 
400° F. After this application the arm was dressed and bandaged, and 
the treatment was repeated on the following day and again on the third 
day. After these three administrations there was no further evidence of 
infection and the parts healed promptly without^further treatment. 

Case 2. A local physician who had infected his right hand at an 
operation came with a distinct swelling in the hand and forearm with 
no evidence of fluctuation or the presence of pus, but with a lymphangitis 
extending up the arm to the axilla, indicating that the infection was well 
advanced. The part was subjected to the same treatment as the pre¬ 
ceding case, and only three treatments were necessary to remove the in¬ 
fection. As a rule this is the ordinary routine before pus is formed in 
the subcutaneous tissues. 

Case 3. The third case represented a condition that had been neglected 
for three months following the infection. When the case came under ob¬ 
servation there were three sinuses discharging pus on the back of the 
right hand. The joints were stiff and the hand useless. The end of 
the index finger was sloughing to the bone. The examination demon¬ 
strated that the tendons were not bound in the sheaths. A good prognosis 
was given, much to the surprise of the surgeon. We instituted the dry- 
hot-air oven treatment which was administered five times and in the in¬ 
terval long applications of reflected incandescent light were made, and the 
forearm and hand were exercised and vibrated between treatments. The 
parts gradually became flexible, the sinuses closed, and the ulceration at 
the end of the index finger healed promptly within three weeks. The 
patient was able to return home with a useful hand. 

In an interview with Hr. Ochsner in Chicago, in the summer of 1917, 
he related his experience with an infection in his own arm, from which 
he had been suffering severely when one of the young men on his staff 
suggested radiant incandescent light. As a matter of fact the Doctor did 
not have much faith in the measure, but he said, “Try anything.” The 
condition was promptly relieved and he was soon cured. Still skeptical he 


THERAPEUTICS OF HEAT 


389 


said to the writer that he had tried the next case, with success, and that 
he now employs it as a routine method, not only in infections, but be¬ 
fore and after operations. 

It will be seen by these reports that, even in serious and neglected 
cases, the measures are successful, so long as a serious destruction of the 
parts or adhesion of tendons in their sheaths has not yet become assured. 

There is no subject among those here treated for which the author 
asks a more conscientious sympathetic investigation of the statements 
made than in septic cases, since thereby fatalities can be curtailed and 
the number of disabled and crippled limbs can be reduced. 

Indurated Acne.—This class of condition is not as a rule successfully 
treated by the usual dermatological methods. During the past twenty 
years very many young men and women have come to the office of the 
writer, and his wife and associate, Dr. Mary Arnold Snow, with their 
faces scarred and in varying degrees covered with large heavy acne 
pustules. The practice of treating these cases by puncture, curettage, 
and antiseptic injections has been of little avail in lieu of what we be- 
lieve to be the curative method of choice—the X-ray. We wish to em¬ 
phasize here the importance of employing other methods with this. 

If, following the last X-ray exposure, there are still a few persistent 
pustules, a small number of applications of the vacuum electrode, pref¬ 
erably employing the static current, but otherwise with the high-frequency 
apparatus, thoroughly applied over the face, will leave the skin free and 
clear of the infection. 

It may prove possible, though in the writer’s experience this has not 
been demonstrated, to cure indurated acne with repeated applications of 
the ultraviolet rays. 

The difficulty in furuncles and crops of boils is that the extension of 
the infection takes place through the lymphatics under the surface of the 
skin, and that the processes crop up like weeds in the garden from a pre¬ 
ceding infection, which the ultraviolet ray may not penetrate deep enough 
to forestall as the X-ray does. It is probable that persistent applica¬ 
tions of the glass electrode currents or of reflected incandescent light would 
be more effective in these cases than the ultraviolet ray. The X-ray has 
filled the role in the writer’s experience without a failure in a very large 
number of cases, at least fifty, and he cordially endorses the method. 

In simple acne the chief indication is to produce contraction of the 
outer layer of the skin and so close the mouths of the sebaceous follicles 
against admission of foreign substance, and consequent black-heads and 
suppuration. It is in the relaxed porous skin of the young man or 
woman at puberty that this condition generally occurs, and the presence 
of these blemishes is a source of great annoyance to those so marked. One 
series of X-ray exposures will usually suffice to effect a cure. This has 
been verified in the experience of numerous writers. 


390 


THERMOTHERAPY 


Fungus Infections of Skin and Scalp.—In these conditions, including 
tinea tonsurans, favus, and sycosis, the X-ray has long held an unques¬ 
tioned reputation as a curative measure. There is, however, no doubt 
that radiant light and heat and the ultraviolet rays, particularly the latter, 
will prove capable of destroying the fungi of these conditions. If the 
ultraviolet rays are employed, a blister should be induced at each exposure, 
and this course should be persisted in. The exposures or applications 
should he made by passing the rays through a quartz applicator and apply¬ 
ing them with pressure over the affected areas. 

Urticaria and Hives.—These affections usually arise from a disturbed 
gastro-intestinal tract, often due to idiosyncrasy to some food, and may 
persist after removal of the cause. They may then he promptly relieved by 
long exposures to incandescent light radiations. 

Treatment of Pulmonary Conditions.—In the treatment of pulmonary 
affections occurring at various sites, there are probably no measures more 
energetic or successful in limiting the process and relieving the condition 
than the administration of radiant energy and diathermy, particularly 
the latter. In the incipient stage of pulmonary tuberculosis, before there 
is danger from hemorrhage, hyperemia induced throughout the lung sub¬ 
stance by high-frequency diathermy offers much through arrestment of 
the process by the local destruction of bacteria on the part of the lympho¬ 
cytes. The X-ray has been demonstrated to increase local lymphocytosis 
and is indicated in conjunction with other measures. These measures offer 
much in relieving the incipient stage of pulmonary tuberculosis, with the 
corrections of habits, or of digestive disturbance or other functional de¬ 
rangements which have lowered the patient’s resistance. 

In acute 'pleurisy there is probably no other measure that will give so 
prompt and complete relief as diathermy, employing two large metal 
electrodes, usually placed laterally on the opposite sides over the lungs, 
directly opposite. The pain and fever disappear as a rule with the first 
treatment, which should be applied with as high a temperature as the 
skin will permit. According to the writer’s experience the duration should 
be for one hour at the first sitting, and the patient should have the wear¬ 
ing apparel all removed and be either wrapped in a sheet or in a kimono 
or pajamas. This precaution is taken in the treatment of all cases in 
which the high-frequency current is employed over large surfaces in order 
that the clothing may not become moistened by the general perspiration 
induced, and so endanger the patient to a future chill from exposure after 
leaving the offices. • 

Bronchitis, Acute and Chronic— Acute .—Acute bronchitis should be 
treated in practically the same manner as pleurisy, the electrodes, how¬ 
ever, being placed anteriorly and posteriorly instead of laterally. The 
same rules as to dosage and precautions against dampness of the clothing 
and thorough drying of the patient before dressing should be observed. 


THERAPEUTICS OF HEAT 


391 


The electrodes in these cases should be approximately twelve inches square. 
When there is a complicating laryngitis, the anterior electrode may have 
attached to it another small electrode placed over the larynx during the 
administration. There are few cases of acute bronchitis that cannot he 
effectively cured in two or three such administrations. There is no more 
gratifying result obtained by any other method in any condition than by 
diathermy in the treatment of acute bronchitis. 

Chronic. —In chronic bronchitis three or four weeks may be required 
to effect absolute relief of the condition. Treatments should be given at 
first daily and continued on alternate days until the chronic cough has 
completely disappeared. It is rarely necessary in the treatment of these 
cases to administer expectorants, as the relief is so prompt and progres¬ 
sive that these nauseating and depressing measures may be avoided. 

Pneumonia.—It has been anticipated from the results obtained in the 
treatment of pleurisy and bronchitis that pneumonia would naturally be 
relieved and possibly cured by the same measures. Clinicians familiar 
with the indications for the use of radiant light and heat have frequently 
shown that pneumonia patients are relieved from cardiac weakness with 
control of temperatures and increased elimination by prolonged applica¬ 
tions of this remedy. The value of reflected incandescent light in pneu¬ 
monia has often been confirmed. Even if not employed throughout the 
whole course, the effects are most gratifying at the time nearing the 
crisis, with indications of cardiac failure and with a weak irregular pulse. 

The following case will illustrate the point of view : 

A physician called the writer in consultation concerning the condi¬ 
tion of his father, an aged man, who was suffering at the period of crisis 
with delirium. The pulse was weak and intermittent and the prognosis 
serious. Prolonged applications of reflected incandescent light were ad¬ 
vised over the chest and body, employing a multiple light applicator. 
The result was highly gratifying. Immediately the force of the pulse 
increased and the beats became regular, the respirations became deeper, 
the delirium disappeared, and the patient made a prompt recovery. 

This was in accord with the principles set forth in the previous part of 
this chapter, where the effect of peripheral heat applications upon the deep 
spinal reflexes is referred to, as affecting cardiac and pulmonary centers. 

There is no danger, whatever, from such an administration, and reflex 
response of the vital centers to peripheral stimulation may be relied upon 
as other stimulants cannot be with the same confidence. 

Reported success from the employment of diathermy in all stages of 
pneumonia has opened up in a most striking way the indications for its 
rational employment. It seems from the reports that, at any stage of 
the infection, improvement is instituted from the first administration. 
It is possible that, when the first severe pleuritic pains and the chill 
mark the onset, if diathermy is at once administered throughout the 


392 


THERMOTHERAPY 


involved portion of the lung, the condition may be promptly aborted, as 
occurs in all cases of pleurisy that are treated at the onset. The increased 
influx of arterial blood to the lungs carries along a multitude of phago¬ 
cytes, which may prove capable of cleaning out the bacteria from the 
lymph spaces, as they do in bronchitis, so aborting the process at the 
outset. Cases of severe pleurisy are promptly arrested and we believe 
that pneumonia may be in the first stages. 

It is only fair to presume that this would occur after the results ob¬ 
tained in the treatment of advanced cases. Nine cases were reported 
by Dr. Harry Eaton Stewart of New Haven, Connecticut, which were 
treated at the Marine Hospital on Staten Island under his direction. In 
every instance lysis was instituted at the first administration of diathermy, 
the current being employed for not longer than one-half hour, and re¬ 
covery was complete in every one of the cases so treated, except one, a 
tenth case, in which there were complicating conditions. In this case 
the findings at autopsy were: “Lobar pneumonia on the right, central 
pneumonia on the left, pleurisy with effusions on the left, septicemia in 
the pleural cavity and an exudate about one-eighth inch thick, which 
covered the pleura.” 

The following are Dr. Stewart’s conclusions: 

“The results in these cases are suggestive that diathermy will have 
a marked influence in hastening recovery in pneumonia. The evidence 
is not at all conclusive. In several of the cases the diathermy was not 
instituted until the time when in favorable cases the temperature might 
be expected to start downward, but it is the opinion of the medical staff 
who selected these as test cases that diathermy helped in their recovery. 
When we have had many more cases to report on, we hope to be able to 
make a more definite statement, but this much we do know, that, with 
every single case, and in almost every single treatment, the temporary 
effect upon the patients was remarkable. Cyanosis disappeared. The 
expiratory grunt, when present, was markedly lessened or stopped entirely, 
respirations were less labored and the patient received from two to four 
hours of very marked relief, in many cases obtaining sound sleep. Now 
diathermy has been ordered as soon as the diagnosis is made in every case 
of pneumonia at the Marine Hospital.” 

In the future, treatment of these cases may be administered at the 
bedside in the hospital or in the patient’s home by the installation of 
portable apparatus wherever the electric current is found. 

Numerous manufacturers are making portable high-frequency ap¬ 
paratus which can be brought to the bedside; when, if the current is 
administered by competent physicians who understand the technic, there 
can be no question as to the expediency of treating cases of pneumonia in 


THEKAPEUTICS OF HEAT 393 

hospitals with diathermy, as may also be done with cases of pleurisy and 
bronchitis. 

Cholecystitis.—In catarrhal cholecystitis the administration of di¬ 
athermy through the gall-bladder affords prompt relief from pain and 
tenderness over the region, and in acute cases promptly restores the nor¬ 
mal circulation with relief of the process. In chronic cases relief will 
be relative to conditions. In cholecystitis, as in all conditions of in¬ 
fection, the presence of pus contra-indicates the use of diathermy. 

Catarrhal Appendicitis.-—The same may be said of the treatment of 
the early stage of appendicitis before the development of pus. It is pos¬ 
sible in these cases properly to dissipate the local infection, relieving 
the pain and muscular tension by either diathermy or radiant light and 
heat deferring recourse to surgery. 

Dietitians are contending that all of these pending cases may be saved 
from operation by the institution of a properly constituted diet—one 
free from excess of animal protein and consisting largely of whole-grain 
cereals, whole-wheat bread, green vegetables, and fruit. 

The joint employment, therefore, of the measures referred to will ar¬ 
rest the process in the early stages and if used conjointly with the estab¬ 
lishment of a correct dietary may restore the normal condition. 

Conditions due to the consumption of various stimulants and narcotics, 
as alcohol and opium, which impair the secretions and irritate the condi¬ 
tions of various organs, particularly of the stomach, liver, and cardia, 
variously disturb metabolism requiring special consideration. 

The Liver.—In cases of acute hepatitis, when the leukocyte count 
will determine that an abscess is not complicating the trouble, diathermy, 
passing the current through the liver with one electrode placed well over 
that organ and the other obliquely on the opposite side of the trunk, will 
arrest an acute condition here as elsewhere. In lieu of diathermy, long 
applications of radiant light and heat for periods of two or more, hours, 
as in cholecystitis, will often afford relief, though not so marked or 
beneficial as by diathermy. 

In the atrophic stage of cirrhosis of the liver, so-called “nutmeg liver” 
with ascites or in the later stages with general anasarca, diathermy some¬ 
times accomplishes good results. 

The following case report will give a clearer understanding of the bene¬ 
fits to be derived from diathermy in this condition. 

Dr. S., who had been suffering for several months with general 
anasarca, with marked ascites, came under the writer’s observation in this 
condition. He was able to get around and to come and go from the 
office, but had given up his active work with the Board of Health and 
other activities in which he was engaged. Diathermy was administered 
daily for one hour with one large electrode placed over the liver, and the 
other, of equal size, obliquely on the opposite side of the body. After two 


394 


THERMOTHERAPY 


weeks’ administration the improvement was marked and the ascites was 
much diminished, and within three weeks his circumference was reduced 
from a highly distended abdomen to normal and his general health was 
so improved that after four weeks he was able to resume his usual routine 
duties. This was the third case of atrophic liver, associated with cir¬ 
rhosis, treated with diathermy with correction of ascites to he recorded, 
the first two having been reported in a paper read before the Greater Hew 
York Society by Dr. J. H. Branth of Hew York. 

It is evident that the hyperemia induced by diathermy relieves the 
ascites. This method is associated with absolutely no danger to the patient, 
and should be given a routine trial for, though the number of cases reported 
as treated in this manner are few, the result has been a cessation of the 
ascites in each case. 

Stomach and Duodenum.—In atonic conditions of the stomach and 
duodenum diathermy will play a most important role in increasing the 
circulation and restoring the normal secretion. Hypochlorhydria is usually 
associated with a lowered condition of the general system with either 
anemia or impairment of the conditions and functions of the splanchnic 
area. The indications for diathermy or reflected incandescent light are 
twofold: (1) to improve the circulation in parts showing impairment of 
function; and (2) to improve the general condition of the blood and so 
improve the functions. If a venous stasis is present in the splanchnic area 
or in cases in which there is ulceration, in the stomach or duodenum, 
diathermy is contra-indicated in the first condition until the disparity is 
corrected and on account of the danger of hemorrhage that might be so 
caused when ulcers are present. The ultraviolet rays and the X-rays offer 
much for the relief of ulcerated conditions of these parts. 

Nephritis.—In nephritis the indications depend upon the type of 
conditions. In chronic nephritis with the presence of albumin and hyaline 
and granular casts in the urine, as associated with hypertension in progres¬ 
sive arteriosclerosis, diathermy offers much for the improvement of the 
circulatory condition. The electrodes should be approximately six by 
eight inches in dimension and one should be placed over the kidneys and 
the other opposite in front. The current should be administered from 
one-half to three-fourths of an hour daily at first, and less often as condi¬ 
tions improve. This method will accomplish much toward improving 
the conditions of the kidney. 

In acute parenchymatous nephritis it may often be a question as to 
whether diathermy will be adequate in overcoming the extreme conges¬ 
tion which may be engorging the kidney. If a marked degree of stasis 
is present, it will not be relieved by heat, which increases, without tend¬ 
ing to decrease the engorgement. Upon administrations in the body oven 
of dry-hot-air, alternating with prolonged applications at the bedside of 
reflected incandescent light radiations applied with the canopy lamps 


THERAPEUTICS OF HEAT 


395 


(Figs. 8 and 9), much relief can he obtained. The static wave current 
would accomplish more in these cases, hut at the present time it is im¬ 
possible to employ it at the bedside. In the future, however, hospitals 
will have these necessary facilities for administering all physical modalities 
with men trained in their employment. 

Body Oven.—The body oven induces three important effects all in¬ 
dicated in kidney lesions: (1) elimination by perspiration; (2) drawing 
the blood into the skin at the surface, thus relieving local congestions; and 
(3) stimulating the cardiovascular centers from the periphery and thus 
increasing the cardiac force. Body-heat administrations, therefore, will 
accomplish much for the relief of the kidney congestion. 

Uremic Conditions .—When possible to administer the body-hot-air 
treatment, employing the method outlined under dry-hot-air technic, it 
is remarkably effective. Often when a patient is in the state of uremic 
coma, relief may follow and the patient emerge from the coma, and a re¬ 
establishing of the kidney function may result. 

Pelvic Conditions .—Pelvic conditions, affecting either the male or the 
female, arise from a disturbance of circulation due to infection or other 
causes. In these conditions, conversive heat plays an important role, as 
also does convective heat, applied with douches for local applications of 
heat. These latter have long held a valuable place in the therapeutics of 
pelvic disturbances. 

In infectious conditions of the pelvic organs, the use of diathermy, 
applied according to the parts affected, using judgment in the placing of 
the electrodes, promises relief. The other methods of heat application 
are not so effective, because the heat cannot he applied with sufficient 
energy and direction to destroy the gonococci which will rarely stand a 
temperature above 104° F. 

There have been published cases in which a course of fever lasting for 
two or three days with a temperature of 104° F. has been followed by the 
disappearance of an acute gonorrheal infection. 

The instituted use of diathermy and radiant incandescent rays has led 
to an understanding of the prognosis for the use of heat therapy as stated 
in the pages on technic. It is possible to administer, in the interior cav¬ 
ities, temperatures as high as 115° F. without danger to the tissues, as 
elsewhere stated, by making the area of the interior electrode one-third the 
size of the electrodes applied to the surface. With electrodes having these 
proportions, the operator is able to use a temperature of 115° F. in the 
cavities of the body. 

Specific Vesiculitis.—In the treatment of specific vesiculitis, by em¬ 
ploying electrodes placed against the vesicles and prostate, it is possible to 
convey the heat through the parts with a temperature theoretically ade¬ 
quate to destroy the bacteria. The applications should he made daily for 
one hour followed by the static wave current, to force out the contents 


39G 


THERMOTHERAPY 


of the vesicles. The conjoint use of the X-ray in these cases is undoubtedly 
an added means of getting rid of the bacteria, which with a thorough 
technic will effect a favorable result. 

Gonorrheal Arthritis. —It has been demonstrated for a long time 
that gonorrheal arthritis will yield to the combined methods of static 
and diathermy. The high-frequency current may be administered either 
with the vacuum or non-vacuum electrodes or metal electrodes against the 
prostate and vesicles. If the infection is superficial, the high-frequency 
current administered through glass electrodes is effective in the pelvic 
cavities, and this may be applied with the same general rule as to in¬ 
tensity with the metal electrodes. When the infection is relieved, the 
arthritis will respond to the usual arthritic treatment. 

The application of heated metals or irrigations, which has been vari¬ 
ously recommended for administration to the prostate gland for treatment 
of prostatitis, possesses very little relative value, owing to the fact that 
convective-heat is not effective in influencing conditions except super¬ 
ficially. The hot-water injections are being administered by physicians 
who are not familiar with the use of electricity, or the effects of heat 
variously applied, and so do not understand how superficial, and of how 
little avail, hot-water irrigations are; whereas, diathermy-heat may be 
applied at temperatures that will be more effective, because the heat is 
produced in the affected part, not around it. When stasis is established in 
a part, however, diathermy is not so effective in reducing the inflammation 
as the static wave current which does effect the removal of the infiltration 
and exudation. 

Dysmenorrhea. —The application of diathermy has been reported by 
Dr. Turrell to possess merit in these cases by passing the current with 
one electrode placed over the sacrum and the other above the pubis. 
If diathermy is used, a better method is to place one electrode in the 
rectum and the other over the pubis. This method is not so effective 
as that with the static wave current with metal electrodes placed in 
the rectum as described under the treatment of prostatitis. By this 
method the infiltration and exudation is removed and the cervical spasm 
relieved. 

Subinvolution. —In subinvolution, the same is true as in the treat¬ 
ment of dysmenorrhea. Heat may accomplish some relief, but not nearly 
so much as the static current applied as stated. 

Amenorrhea. —There is no question as to the indication for diathermy 
in amenorrhea, passing the current through the pelvis with one electrode 
over the sacrum and the other over the iliac regions. In lieu of diathermy, 
radiant light and heat may be of great value in these cases. 

Uterine Hemorrhage.— In cases of uterine hemorrhage, there will 
be nothing accomplished with the thermic methods, but here the X-ray 
and static wave current will meet the indications. 


THERAPEUTICS OF HEAT 


397 


Salpingitis. —Treatment should be given, using the vacuum or non¬ 
vacuum vaginal electrode in the vagina with the other electrode placed 
above the pubis, using diathermy as outlined in the treatment of vesicu¬ 
litis. The same method can be employed in treating early cases of 
pyosalpinx. 

Ovaritis. —This is usually associated with some conditions affecting 
the uterus, and local applications of conversive-heat may give great tem¬ 
porary relief from pain; but lasting relief should come from the cure 
of the uterine condition. The use of diathermy will do much toward 
relieving this painful affection, but the static wave current is the method 
of choice applied with the electrode placed against the uterus at the rectal 
site, which will relieve the venous stasis or congestion and give prompt 
and complete relief in most cases. 

Hot vaginal douches, which have occupied a recognized place for many 
years, as introduced by Dr. Robert Emmett, are of undoubted value in 
mild pelvic conditions, however, with convective-heat effect only. Douches 
when employed should be given with the patient upon the hack with a 
proper douche pan and the hips elevated. It should be administered with 
a temperature of 108° F. to 110° F., and for at least one-half hour—in 
order to relieve local congestion. Hot douches do not produce so marked 
an effect as is obtained by conversive heat with diathermy. 

Non-infective Local Conditions. —In the treatment of local conditions 
of non-infective origin, diathermy plays an important part if applied in 
the early stages. 

Neuritis .—This may be relieved within the first twenty-four hours and 
sometimes later by the application of diathermy and radiant light and 
heat. 

Sprains .—In the very early treatment of sprains, diathermy and radi¬ 
ant incandescent light may be effective in relieving the local condition, but 
not as a rule. Here the static current alone is the indicated method. 

Contusions or Bruises .—The same measure as described above will be 
found to be effective in relieving these conditions. 

Fractures .—In the treatment of fractures, the use of radiant light 
applications made daily with one of the splints removed, so that the light 
can affect the part, will greatly relieve the pain and hasten repair. * The 
open treatment and applications of light with extension play an impor¬ 
tant role in the treatment of Colies’ fracture. The period of repair may 
be so shortened that convalscence often occurs in less than four weeks. 

Extensive Bums .—Burns upon the body are very much benefited by 
the use of reflected radiant light and heat. The treatment for the first 
half hour is very painful, and the patient will recoil from it and say 
that it is making him worse, but if persisted in he will later make no 
further protests. This has been demonstrated in the treatment of chil¬ 
dren in Bellevue Hospital. There was at first some controversy between 


308 


THERMOTHERAPY 


the staff and aides concerning the use of radiant energy, but it has finally 
been established as a routine method and many lives have been saved and 
sufferers made more comfortable by the established application of reflected 
light followed by soft dressings to protect the parts. The light should be 
given with prolonged applications twice daily for at least one hour. Re¬ 
pair is prompt, as the increased circulation in the true skin brings about 
a very active improvement, healing as a rule without scarring. 

Gangrene .—In senile gangrene affecting the extremities, it is remark¬ 
able what relief can be afforded in many cases by long applications of re¬ 
flected incandescent light, persisted in until the parts often heal over. 

Endarteritis Obliterans .—The pathology of this condition is obscure, 
but the results from the employment of diathermy and radiant light and 
heat have been very successful. The administrations of reflected light 
should be given with long exposures with the applications made over both 
extremities, including the parts above the knees. When diathermy is em¬ 
ployed, the better way is by the method described in the section on 
Technic, immersing the feet in water, resting upon an electrode in one- 
half inch depth of a salt solution and the other electrode over the sacrum. 
In this way it is possible to pass the current upward through the limb 
and all of the structures in the path of the current. Either this method 
may be employed or the cuff method by placing electrodes around the 
ankles, and the other over the sacrum, using a bifurcated cord attached 
from one side of the d’Arsonval to the two ankle electrodes. This method 
is contra-indicated if the effect is to be general. 

Erythromelalgia .—Some temporary relief can be derived from the 
application of heat and diathermy in these distressing cases, but in the 
writer’s experience it is impossible to give lasting or permanent relief to 
these unfortunate sufferers. 

Myocarditis .—The employment of diathermy through the heart for 
myocarditis has shown remarkable results as verified by electrocardio¬ 
grams. The current is applied with one electrode placed over the scapula, 
posteriorly, and the other electrode over the cardia in front. The elec¬ 
trodes should be about six inches square, and the current used with a mod¬ 
erate degree of heat, not as great as in the treatment of other thoracic con¬ 
ditions. The treatments should be given daily at first for one-half hour, 
and then on alternate days. 

Desiccation or Endothermy. —This method for the treatment of local, 
malignant, and other conditions, as introduced and developed by Dr. 
William L. Clark of Philadelphia and later by Dr. Wyeth of New York, 
is of unusual value for the treatment of local affections of the skin, mucous 
cavities, tonsils and hemorrhoids. 

Apparatus, as described elsewhere, must deliver from the one pole 
Oudin terminal, under perfect control, what has been described as a cold 
spark; in other words, a fine spark of such quality that when applied to 


THERAPEUTICS OF HEAT 


399 


paper it will perforate the paper without giving any evidence of burning 
or charring it. In other words, it will not ignite, burn, or char, but 
perforate the paper. This quality of spark is of small amperage and pro¬ 
duces a distinct desiccation or drying, removing fluids from the skin, and 
was so termed by Hr. Clark for that reason. 

The tissues treated by this method, if applied to the extent of produc¬ 
ing complete removal of all fluids, are practically killed. 

When this quality of spark is applied over a small keratosis of the 
skin, the dried tissue may be removed by the curet, leaving a smooth under¬ 
lying skin. 

It is employed with a very short spark to remove keratoses, warts, 
and moles. The application may not affect the cutis vera unless so de¬ 
sired except in its outer layer, and, from the nature of the effect, causes 
drying without bleeding. When, however, it is desired to destroy malig¬ 
nant growth of varying thickness or depth, such as epitheliomas, the 
current must be applied with sufficient energy to destroy the growth beyond 
the diseased tissues; otherwise there will be a prompt recurrence and a 
more rapid growth than before. 

In treating such a condition it is customary to go well around the out¬ 
side of the malignant tissues at the outset. After destroying a circle be¬ 
yond the growth, including the deeper layer of the skin, the growth is 
then attacked directly. The operation, except in extensive growths, may 
be done under local anesthesia. In small superficial areas there is usually 
so little pain or discomfort that an anesthetic is not necessary. 

The question always arises as to what method to employ in the treat¬ 
ment of an epithelioma on the surface. With the X-ray or radium prop¬ 
erly employed it is possible to remove epitheliomas and rodent ulcers with¬ 
out producing any scarring or evidence of the former presence of the 
growth. When removed by the desiccation method, there may be a slight 
scarring following the recovery. 

When an epithelioma is situated where some important structure, such 
as the tear-duct, would be destroyed by the desiccation method, the X-ray 
is the method of choice ; for, as has been shown, epitheliomas have been 
cured by the application of the X-ray in the inner canthus of the eye 
involving a tear-duct which has been obstructed and was restored after 
the X-ray had cured the growth, showing the remarkable selection of 
diseased tissues leaving the normal tissues intact. If desiccation had been 
employed under these conditions, the canal would have been destroyed. 

The application with endothermy should be made deep enough to get 
to the bottom of the involvement. It is customary to put the needle carry¬ 
ing the current in and out of the mass, moving it about until the dis¬ 
eased tissues are entirely destroyed. If extensive and deep, cut away 
the desiccated tissues with curved scissors, and then apply the current 
to the deeper structures^ insuring the removal of all of the diseased cells.. 


400 


THERMOTHERAPY 


It is possible by this thorough method to destroy all of the malignant tis¬ 
sues to considerable depths, as has been shown by Dr. Clark. Thus not 
only are the soft structures destroyed, but diseased bone as well. In 
the case of bone, however, the area treated will later separate as a se¬ 
questrum or may be curetted or chiseled away at the time of operation. 

This method of treating malignant growths is particularly applicable 
to the tongue, lips, and fauces, as well as to the larynx. In the latter 
event it is necessary to perform a tracheotomy and close the larynx, so 
that there can be no escape of tissue to the lungs. It is remarkable how 
few cases of epithelioma of the lip or tongue are followed by recurrence. 
If treated early, when the growth involves a small area, and even where 
considerable tissues have been involved, the prognosis is good if properly 
done. There have been numerous successes in the treatment of malignant 
conditions of the tongue and fauces, and uniformly of the lips by this 
method. It is the method of choice in all conditions involving the mouth 
and fauces, and now a greater percentage remain cured by this method 
than by the knife, radium, or X-ray. 

Tonsils .—The treatment of tonsils by desiccation includes local treat¬ 
ment, both for the purpose of closing the crypts, and for removing por¬ 
tions of the tonsils. At the present time the X-ray treatment seems to 
have supplanted the desiccation method of treating tonsils, though the 
latter is still largely employed by operators who have acquired a skillful 
technic together with the X-ray. 

Hemorrhoids .—For the treatment of hemorrhoids, the desiccation proc¬ 
ess is particularly advised. When operations have been done by the clamp 
and cautery method there have often been marked strictures in the rectum 
following the operation. When the desiccation method is employed, there 
is no stricture. 

The desiccation operation consists of applying a clamp to the hemor¬ 
rhoid and then desiccating the pile and shearing off with the scissors the 
part above the clamp; after which the desiccation spark is applied back and 
forth between the jaws of the clamp and the clamp removed. 

By the desiccation method the mucous membrane is sealed off, so af¬ 
fecting it as to leave no structures or danger of secondary hemorrhage. 

Phlebitis .—There are few conditions that give greater evidence of 
the failure of wet dressings, and other local applications of heat, than 
phlebitis. Many cases of varicose veins come under observation that might 
have been relieved in the acute inflammatory stage. During past years 
many of these cases have come under the writer’s observation in the acute 
stage that have been promptly relieved. 

When seen during the acute stage, the prolonged application of radiant 
light and heat followed by adequate administrations of the static brush dis¬ 
charge will remove the infiltration from the inflamed vein and sufficiently 
increase the lumen to permit the blood to pass. The application of radiant 


IMPAIRED METABOLISM 


401 


light and heat relieves the tension, and the static brush discharge applied 
over the inflamed vein removes the infiltration; thus an acute phlebitis is 
promptly cured in all cases in which the walls have not become adherent. 
The writer and his associate have accomplished this in all early cases, 
twice in cases involving the great saphenous vein. 

Varicose Ulcers .—These ulcers, arising, as they do, from obstruction 
in the circulation in parts remote from the obstructed vein, cause the 
tissues to be starved or impoverished from lack of blood. To heal the ulcer 
a return of the circulation is required. This may often be accomplished 
by long and frequent exposures to reflected incandescent rays; but in much 
less time and with greater certainty by the added use of the static brush 
discharge, which, if thoroughly applied, will not only remove the thick¬ 
ened margin of the ulcer, but also the edema from the swollen limb, thus 
causing the blood to flow back to the region of the ulcer. The ulcer should 
be kept well bandaged during the course of the treatment. To prevent 
recurrence the limb must be supported by proper stockings or bandages. 


IMPAIRED METABOLISM 

In conditions of impaired metabolism when the functions of the 
organism are, for any reason inactive, or relatively so, the administration 
of conversive heat, either by the use of radiant light and heat or diathermy 
is indicated. We often find this condition in patients who are victims 
of constipation, who are toxic following severe illness, or who are in feeble 
health from various causes. 

In these conditions the benefits derived from accelerating the gen¬ 
eral circulation and that of impaired organs, and stimulating the deep 
cardiac and other vital centers are due to stimulation of metabolism. Such 
applications should be given short of producing fatigue and with an in¬ 
tensity not sufficient to cause the patient any sense of depression. 

In patients who are anemic, either from hemorrhage or some other 
form of secondary anemia, first apply radiant light and heat to the ex¬ 
tent of inducing an active hyperemia of the skin, and then follow im¬ 
mediately, while the blood is actively circulating at the periphery, by ex¬ 
posures to the ultraviolet rays. The ultraviolet exposures should always 
be made short of blistering, but sufficient to produce an active hyperemia 
of the skin. These applications are as a rule given on alternate days, 
and the length of exposure to the ultraviolet rays may, in most cases, be 
doubled at each sitting, without danger of causing too great reactions. 

The following case report will illustrate the success of this method, the 
patient having been given no internal medicine to increase the red cells, 
but having been treated as above described: 


402 


THERMOTHERAPY 


Mrs. Y.—June 28, 1922; red cells per c.mm., 2,240,000; whites, 
4,800; hemoglobin, 68 per cent. 

—July 6, 1922; red cells per c.mm., 3,520,000; whites, 5,600; hemo¬ 
globin, 68 per cent. 

—Aug. 4, 1922; red cells per c.mm., 3,500,000; whites, 5,600; hemo¬ 
globin, 70 per cent. 


POSTOPERATIVE USE OF RADIANT LIGHT AND HEAT 

There is probably no indication for the use of any measure of greater 
importance than the use of radiant light and heat after operations. When 
the surgeons are brought to appreciate the value of this measure in opera¬ 
tive cases before and after operations, bearing in mind that the action of 
radiant light is practically germ-destroying in character, even when de¬ 
void of the ultraviolet rays, the measure will be used following operations 
in some cases while the parts are still uncovered. Prolonged applications 
of light over the surface bring an increased blood supply to the tissues 
that have been shocked from trauma at the operation and so hasten the 
process of repair and relieve the patient from much of the soreness and 
suffering immediately following operation. For convenience the patient 
may be removed to another room provided for the purpose where the dress¬ 
ings may afterwards be applied. Conversive heat is invaluable, not only 
as a means of hastening repair, but for the comfort of the patient. The 
only contra-indication is the possibility of inducing hemorrhage in tis¬ 
sues not properly sealed off. 

Following such an application the patient will lapse into a quiet state 
with prompt relief from much of the pain and tenderness due to operation. 
Providing the light is not applied directly over the tissues, but over a 
thin dressing permitting a degree of light and infra-red rays to penetrate, 
a great deal of relief can so be afforded the patient. Only those who 
have been subjected to painful conditions following an operation and been 
thus indulged can appreciate the relief experienced. 


THE OPPOSITE EFFECTS OF THE X-RAY AND RADIANT LIGHT 

The distinctly opposing effects of the X-ray and radiant light cannot 
be too often stressed, particularly so now that there are so many new men 
in the X-ray field employing the X-ray in therapeutics. 

The writer discovered, more than sixteen years ago, that it was not 
expedient to employ the light and the X-ray with the object of doing 
team-work, when he found, after the use for one month of the combined 
method, that cases under treatment were making no progress as they pre- 


EFFECTS OF X-RAY AND RADIANT LIGHT 403 

viously had under X-ray treatment. The reflected light had been com¬ 
bating the effect of the X-ray to a degree that nullified its action upon 
the diseased tissues. Further experience has confirmed this discovery 
and demonstrated that distinctly opposite effects are produced by the two 
modalities—an inhibitory effect by the X-ray and a stimulating effect 
by radiant light and heat. This has been further confirmed in the man¬ 
agement of X-ray dermatitis; for there is no measure so effective in pre¬ 
venting or relieving this condition as reflected light and heat. It is very 
effective both in promptly restoring and in anticipating an X-ray der¬ 
matitis in tissues overexposed. This is one of the important uses of 
radiant energy and one which is the least appreciated by the radiologists 
who neglect the other rational methods. 

The ultraviolet rays have been demonstrated to be of great value as a 
prophylactic to X-ray dermatitis, because they do not penetrate the skin. 
They may also be employed to protect the skin during courses of X-ray 
treatment. The ultraviolet rays may also be used in cases of X-ray der¬ 
matitis before or following the reflected incandescent radiations, and as 
a prophylactic before X-ray exposures. 

Chronic X-ray Dermatitis. —In cases of this character, occurring on 
physicians 7 and radiographers 7 hands, there is nothing that will give greater 
relief than the judicious use of the ultraviolet rays. This is a very im¬ 
portant observation, and one that should be known because of the benefits 
to be derived. 

Osteomyelitis. —During the treatment of post-war cases the use of 
the ultraviolet ray and diathermy have been recognized to he of great 
value in the treatment of osteomyelitis. There are numerous cases re¬ 
ported that have received only the ultraviolet treatment, and that have 
shown progress for obvious reasons. As these rays do not penetrate to 
the deeper tissues, the use with diathermy is essential. The exposures to 
the ultraviolet rays in the treatment of these conditions should he made 
on alternate days and the application of the ultraviolet rays should then 
precede the application of diathermy, because the more anemic the tissues 
are, the deeper the rays will penetrate. 

In this chapter the writer has endeavored to establish the principles 
of action of. the physical measures employed, as to their physiological 
effects upon the living tissues, the practical technic of administering the 
different methods for producing thermic effects upon the tissues, and finally 
their application to therapeutics. 


404 


THERMOTHERAPY 


REFERENCES 

Baruch. An Epitome of Hydrotherapy, 54-59. 

Forchheimer. Therapeusis of Internal Diseases, 3d ed., i, 434, 435. 
Hess. Journ. Am. Med. Ass., June 30, 1922. Quoted in Am. Journ. 

Electrotherap. & Radiol., 257, Aug., 1922. 

Humphries, Howard F. Melted Paraffin Wax Baths, Am. Journ. Elec- 
trotherap. & Radiol., 62, Feb. 1, 1919. 

Kellogg, J. H. Journ. Advanc. Therap., xxiii, 86. 

Maxwell, Clark. Matter and Motion, Encyclopedia Britannica, xciii. 
Meyer. Bier’s Hyperemic Treatment, 20, 22. 

Pitcher, Herbert F. 'Phototherapy in General Practice, Journ. Advanc. 
Therap., 433, Sept., 1906. 

Price, Byron S. Am. Journ. Electrotherap. & Radiol., 239, Aug., 1922. 
-Thermo therapy, Ibid., 17, Jan., 1922. 

Snow, William B. Radiant Light and Heat and Convective Heat, 20, 
93, 97, 1909. 

-High Potential Currents of High and Other Frequencies, 2d ed., 

241, 1910. 

-Sajous’ Analytic Cyclopedia of Practical Medicine, v, 364. 

Stewart, Harry Eaton. Diathermy in Pneumonia, Am. Journ. Electro¬ 
therap. & Radiol., 326, 327, 1922. 

Thomson, Sir William. Encyclopedia Britannica, 11th ed., xiii, 146. 
Zinnser. Infection and Resistance, 1st ed., 285. 





CHAPTER XI 


HYDROTHERAPY AND BALNEOLOGY 
William J. M. A. Maloney 

HYDROTHERAPY 

History. —Man from his advent has daily experienced the beneficent 
action of water. Instinctively he drank when thirsty, washed when un¬ 
clean, and bathed when tired and heated. The knowledge that water is 
essential to the maintenance of life was among the first of all human 
acquirements. The relation of vegetation to water and the cleansing 
action of the rain, streams, and seas must have been recognized even by 
the earliest forms of human intelligence. Primitive man felt the need 
of water, saw its wide dominion in the world, wondered, perhaps, at the 
mysterious forces which dictate its form and motion, and in his dawning 
imagination endowed it with preternatural powers. 

Symbolism characterizes all primitive mental expression. It was 
therefore natural that man should use water, not merely when ministering 
to his bodily cleanliness, but also when striving to convey ideas of moral 
purification. As late as the beginning of the Christian era we find this 
application of water even among the cultured Romans. Pontius Pilate, 
when he wished to disclaim guilt and responsibility for the Crucifixion, 
called for water and washed his hands before the comprehending eyes of 
the clamoring mob. 

Analogous use of water entered into spiritual matters. To-day Hin¬ 
dus still seek grace by bathing in their sacred streams; Mohammedans 
perform extensive ablutions as an essential preliminary to prayer; Jews 
wash in prescribed fashion at fixed periods in order to conform to the 
law; and Christians are sprinkled with, or immersed in, water to wash 
them from the stain of a original sin” in the sacrament of baptism. 

This symbolic use naturally led to the inclusion among religious prac¬ 
tices of the application of water in the treatment of mere bodily ailments. 
So hydrotherapy developed under sacred auspices, and the use of water as 
a healing agent acquired the dignity of a religious ceremony. Waters 
from sources distributed over the greater part of the Old World gained 

405 


406 


HYDROTHERAPY AND BALNEOLOGY 


more or less local reputations for special efficacy. Sometimes a natural 
peculiarity lent awe to these waters and served to strengthen faith in their 
remedial powers. The periodic filling of the well of Bethesda in Jeru¬ 
salem and the annual rise of the Nile are typical examples of such peculi¬ 
arities. The moment of the appearance of these unique phenomena sig¬ 
nified to the faithful that the endowed waters had then attained the climax 
of their curative powers. 

In some instances the special attributes of the waters were disclosed 
by revelation or by happy experience to the pious. To some sources was 
given a specific virtue; thus, the famous well of St. Triduana and the 
waters of Siloam were efficacious in eye diseases; lepers were made clean 
in the Jordan; abdominal diseases were healed at the well of St. Gin- 
golph; and madness, sterility, and most other afflictions were cured by 
waters from appropriate sources. The Jordan, the Nile, the Ganges, the 
well at Emmaus, and a few other holy waters possessed such wondrous 
powers that they acted practically as panaceas. 

The waters of Bethesda now rise almost unheeded; the pious blind no 
longer seek the once all-powerful well of St. Triduana; and, except among 
the adherents of the Greek Church, faith in the properties of the sacred 
waters of the Jordan is almost dead. As the popularity of one source 
ebbed that of another rose. In our own times to the well at the Grotto of 
Lourdes, near the Pyrenees, and that of St. Winifred at Holywell, in 
Wales, seem to have been transferred many of the marvelous properties 
which centuries ago were vested in the holy places of the Orient. From 
these wells wonderful cures are daily reported by eminent physicians 
whose belief in the verity of the phenomena they record is above suspicion 
and beyond question . 1 

Although substances of greater potency, but of less traditional and 
spiritual force, have had their day and now are irretrievably forgotten, 
water has preserved throughout the ages its reputation as a remedial 
agent, owing largely to this fostering by religious bodies of faith in 
hydrotherapy. 

The rudely material benefits of bathing were early appreciated. So 
widespread in ancient times was the custom of bathing that the Greeks 
and Lacedaemonians had not only private but public baths. Alexander 
the Great is recorded to have marveled at the magnificence of the baths 
of the conquered Darius. But the apostles of bathing were the Romans. 
The Romans elevated bathing to a cult. The splendor of their baths is a 
salient feature of their civilization. In the Roman conquests a bath was 
built as soon as the barbarians gave the invaders a moment’s leisure. The 
more settled the new colony the more ornate was the bath. Elaborate de¬ 
scriptions of these early baths and interminable dissertations upon bath- 

1 The modus operandi of these cures may he just as satisfactorily explained in 
other ways and, moreover, the cures can be performed in many other ways.— Editor. 




HYDROTHERAPY 


407 


ing survive in the writings of many of the ancient authors, particularly 
Pliny, Seneca, and Juvenal. The use of water alone was not fashionable 
even in the humblest baths. Oils, perfumes, spices, and other adjuvants 
enhanced the aesthetic pleasures of these institutions. Together with bath¬ 
ing the Romans associated massage and physical exercises. The untram¬ 
meled license which characterized many of the public baths of the Romans 
brought bathing under the ban of the reforming zeal of the early Christian 
Fathers and perhaps conduced to the not overscrupulous cleanliness which 
sometimes served to eke out the penance of the pious anchorites who re¬ 
tired into desert places, and to the strikingly insignificant role which water 
plays in the ritualistic practices of the Christian church. 

The Roman influence upon bathing is accentuated in our period partly 
because the Romans, were so prodigal in their bathing resources, but mainly 
because our civilization is in direct succession to theirs. But knowledge 
of the cardinal uses of water probably dates from the dawn of man. The 
ancient Egyptians, Piets, Celts, Turks, Moroccans, Japs, Indians, and 
Mexicans all used forms of vapor baths. Besides baths of water—ice, 
vapor, hot, cold, river, spring, well, and sea water—other media such as 
sand, mud, peat, wine, milk, and even blood were used. 

The therapeutic use of water by physicians is as old as the art of medi¬ 
cine. Hippocrates was hardly an enthusiast for baths, but he advocated 
them under certain conditions in several of his writings. Celsus praised 
house baths but was reticent about the use of mineral waters. Aretseus 
of Cappadocia, Athenseus, and Rufus of Ephesus wrote at length upon the 
merits of certain thermal baths. Agathinus was the apostle of cold baths. 
Galen said little of baths. Fallopius alluded to the diseases which may 
be benefited by the water at Lesbos, Mitylene., and other places. Antyllus, 
Oribasius, TEtius, Paul of H]gina, Cselius Aurelianus, and countless others 
through the ages lauded the uses of water. To enumerate the physicians 
who have practiced water treatment would be merely to catalog the fathers 
of medicine. But until the scientific renaissance of the last century the 
properties and actions of water remained clouded in superstition and 
empiricism. The pioneer work of Winternitz, Brutenbach, Baruch, 
Thayer, and others has now definitely established the physiological prin¬ 
ciples upon which the action of water depends. Out of the chaos a certain 
amount of order and system has been evolved; a rational basis for the 
therapeutic employment of water has been defined; and the science of 
hydrotherapy, which deals with the action of water upon the human body, 
has been erected. 

Here we shall confine our attention almost exclusively to water. The 
physical characters of water will first be considered; then the physiologi¬ 
cal principles of its various actions will be discussed; next, the ways in 
which it can be used will be described; and, finally, its application to 
disease will be dealt with. 


408 


H YDKOTHERAPY AND BALNEOLOGY 


Properties of Water 

A brief outline of the properties of water is essential to a clear under¬ 
standing of its uses. Its distribution is universal. It exists in and can 
readily be transformed into solid, liquid, or gaseous form. 

Under ordinary atmospheric pressure, at the temperature of 0° C. it 
becomes ice; between 0° and 100° C. it is liquid; about 100° C. it exists 
as steam. In changing from fluid to ice a remarkable absorption of heat 
takes place: if a kilogram of water at 0° C. and a kilogram of water at 
79° C. be mixed the resulting mixture has a temperature of 39.5° C.; but 
if a kilogram of ice at 0° C. be added to a kilogram of water at 79° C., 
the ice disappears and two kilos of water with a temperature of 0° C. 
remain. This heat absorption explains the great efficacy of ice baths in 
bringing about a lowering of temperature in cases of fever. 

Similarly in passing from liquid to steam a tremendous amount of 
heat is rendered latent; hence allowing water to evaporate from a surface 
is one of the best means to produce cooling. 

Eurther, water has a great capacity for absorbing heat; thirty-one 
times as much heat is required to raise one unit of water through one 
degree of temperature as is required to raise one unit of platinum one 
degree. 

Water cools relatively slowly. It is therefore invaluable as a medium 
for abstracting heat, for storing heat, and for applying heat. Its utility 
as a thermal agent is further enhanced by the ease with which its tem¬ 
perature can be measured, regulated, and controlled. As a fluid it mixes 
with solids to form pastes, the consistency of which can be altered at 
will; it also permeates most textures, so that its application can be re¬ 
stricted or adapted at will to any surface. 

Water can readily be applied with varying and regulated pressure. 

When water holds a small amount of a salt in solution it is one of 
the best of the electrical conductors and can be used to insure intimate 
contact between the body and electrodes, or a bath may be arranged in 
a circuit, through which faradic or galvanic currents may be passed. 
When currents are passed through aqueous solutions decomposition or 
electrolysis of the solution occurs. 

Thus., the constant current decomposes water into hydrogen and 
oxygen. The elements at the moment of liberation from their compounds 
are said to be nascent. The action of the nascent elements produced by 
such electrolysis is relatively powerful and is utilized in certain forms 
of baths. 

Water is thus an ideal medium for the application of cold and heat, 
electricity and pressure, owing to the simplicity, precision, and rapidity 
with which these physical forces can through it be controlled. Its power 


HYDROTHERAPY 


409 


in combating disease depends almost solely on its property as a medium. 
Its physiological action, when a medium, is essentially that of the physical 
force which it is conveying. We shall, therefore, before proceeding to 
discuss the specific therapeutic uses of water in detail briefly consider 
the various actions of heat, cold, pressure, and electricity upon the body. 

The chief sphere of hydriatic medication is the skin. The physiologic 
action of water upon the skin is very simple. So far as hydrotherapy is 
concerned the skin may be regarded as a great sheet of imperfectly shel¬ 
tered blood-vessels and nerves. The effect produced by water upon the 
skin is merely the expression of the reaction of the blood-vessels and 
nerves to the physical forces applied by the water. Congestion or ischemia 
of a part depends upon the state of the blood flow in the capillaries; the 
capillary system is controlled mainly by the contractibility or tone of 
the arterioles; and upon the condition of the arterioles hangs the efficiency 
of the whole circulatory mechanism. 

The skin is richly supplied with nerve terminals which are elaborated 
sometimes into special sensory end organs. Just as the network of vas¬ 
cular capillaries opens into larger channels and thus links the peripheral 
circulation directly with the heart, so the terminal cutaneous ramifications 
of the sympathetic and sensory nerves are gathered together into trunks 
and pass to the central nervous system. A stimulus to the skin thus may 
powerfully affect the vascular and nervous arrangements of the whole 
body. The skin is in fact an externalized regulating mechanism for the 
circulatory and nervous systems. 

Some areas of the skin have certain definite nervous relations to the 
viscera. 

An organ may be reflexly influenced through a particular area of 
skin, and affections of organs may reflexly influence special skin areas. 
Our knowledge of these areas we owe to Head and Mackenzie, and it 
enables us so to guide and restrict our operations that by the simple 
bloodless procedures of hydrotherapy we can influence viscera with as 
much certainty as if we were exposing them by a surgical operation. 

The skin, however, besides being an organ of sensibility, has also 
secretory, excretory, and heat-regulating functions. These are subservient 
to nervous and vascular control. A stimulation of a cutaneous secretory 
nerve induces an increased flow of sweat and a local increase in the blood 
supply. An increase in the blood supply usually involves an increased 
sweat secretion. The heat regulation of the body is largely attained 
through the skin. In overproduction of heat by excessive muscular action, 
or in exposure to excessive external heat, the cutaneous capillaries dilate, 
and sweating increases; the evaporation of the sweat from the skin absorbs 
much of the surplus heat from the body. If exposed to cold the cuta¬ 
neous vessels contract and sweating diminishes; the body heat is thus 
conserved. Urea, xanthin, and other decomposition products of protein 


410 


HYDROTHERAPY AND BALNEOLOGY 


metabolism may be demonstrated in the sweat; the sweat glands, just like 
nearly all glands, have a vital selective affinity for certain substances 
circulating in their blood supply. 

But as the secretory, heat-regulating, and excretory mechanisms are 
merely outward evidences of vascular and nervous activities we shall first 
consider the action upon these activities of each of the physical forces 
utilized in hydrotherapy. 

Physical agents such as cold act mainly by virtue of their irritant 
properties. Within certain ‘ limits of intensity a stimulus to the skin 
produces similar effects, whether it be caused by chemical or physical 
action. Weak cutaneous irritants narrow the arterioles and raise the 
blood-pressure; the increased peripheral resistance thus produced causes 
the heart to contract more rapidly. On the contrary, intense cutaneous 
irritants fatigue and paralyze the normally existing innervation of the 
blood-vessels and produce a relaxation and dilatation of the peripheral 
arterioles with diminution of pressure; at the same time the inhibitory 
action of the pneumogastric slows and intensifies the cardiac contraction, 
and, when excessive, may produce death by vagus tetanus. 2 

Cold. —The application of cold is perceived with varying delicacy on 
different parts of the skin. The local and general disturbances are de¬ 
pendent upon the degree and duration of the cold employed and the extent 
of the area to which it is applied; that is, to the intensity of the stimulus. 
Long-continued application of severe cold deleteriously affects the vitality 
of the tissues to a degree depending upon the resistance of the tissue ex¬ 
posed. And when the cold is severe, besides the coldness, a pain element 
is noticeable in the sensation. 

The application of sudden cold produces first a sharp inspiration, 
next a pause, and then a long expiration which is followed by frequent 
and shallow breathing. This reaction is the basis of one of the best known 
and most efficient methods of resuscitation of the still-bom; indeed, it is 
alleged to be an essential stimulus to the establishment of respiration at 
birth. In breech presentations, in which a premature onset of respiration 
might be attended by fatal consequences to the child, accoucheurs care¬ 
fully swathe the extruded limbs in warm clothes. The effect of cold is not 
confined to the respiratory mechanism; consciousness is stimulated by its 
application, as may be seen in the awakening of the dormant attention of 
hysterics, and in the sobering of the drunk, by cold affusions. Cold is one 
of the most powerful nerve stimulants we possess. 

Owing to the stimulation of the cutaneous nerves the voluntary and 
involuntary muscles are influenced. Investigations by means of Mosso’s 
ergograph have proved conclusively that cold is able to increase enor¬ 
mously the resistance of muscle to fatigue, and also to restore the efficiency 
for work to muscle which is already fatigued. A slight increase in the 


2 Roehrig and Naumann quoted by Baruch. 



HYDROTHERAPY 


411 


tonicity of voluntary muscle is produced. And in involuntary muscle 
the stimulation is evident in “goose skin/’ and in shivering. 

This increase of muscle tone and of muscular action and the vascular 
redistribution which they cause serve to augment animal heat and partly 
to compensate for that which is being lost. Perceptible cold produces, 
partly by direct action and partly by reflex action upon the vasomotor 
center in the floor of the fourth ventricle, a local constriction of the blood¬ 
vessels. The blood is, in consequence, diminished in the cooled part, and 
a concomitant hyperemia is produced in other areas. 

The result of the contraction of the involuntary muscle fibers in the 
skin and of the sensory stimulus given to the central nervous system is 
a sudden diminution in the caliber of the cutaneous capillaries. This nar¬ 
rowing of the arterial and venous river bed raises the blood-pressure, in¬ 
creases the endocardial stimulation, and causes an automatic increase in 
the force and speed of the ventricular contractions. 

The increased cardiac action propels an augmented supply of blood 
through the capillaries, which are thus expanded to the fullness of their 
capacity. The increased force of the heart is maintained for some con¬ 
siderable time. 

The contraction of the cutaneous vessels diminishes the skin secretion, 
increases the blood-pressure in the vessels of the deeper structures, and 
stimulates their vital processes. One well-known consequence of this ele¬ 
vated blood-pressure is diuresis. The increased blood-pressure, the 
increased force and frequency of the heart’s action and the increased 
blood supply to the kidney all tend to enhance the diuretic action of 
cold. 

James Tyson measured the amount of urine and urea excreted daily 
by a patient suffering from enteric fever, who was being treated by cooling 
(Brand) baths. He found that the amount of urine secreted was vastly 
increased. Before the Brand bathing was begun the urine, as is usual in 
febrile conditions, was scanty and very concentrated. After the bathing, 
as much as 1,980 c.c. of urine was excreted daily. As the toxicity and 
the amount of contained solids were increased, not only was the me¬ 
chanical transudation of fluid through the kidney augmented, but the 
selective secretory properties of the renal epithelium were enhanced also. 

Experiments have proved that in addition to these changes there are 
also remarkable alterations in the relative proportions of the corpuscular 
elements of the blood. 

Cold baths produce a leukocytosis which persists at least for one and a 
half hours. The increased blood-pressure in the spleen and in the lym¬ 
phatic glands, consequent on the general peripheral vascular contraction, 
may wash out the white cells from these viscera into the general circulation. 

The reestablishment of the normal ratio among the blood-cells in the 
course of one or two hours from the time of the cold application shows the 


412 


HYDROTHERAPY AND BALNEOLOGY 


alteration in the blood to be due to transitory changes in the circulatory 
system, in the cardiac tone, and in the lumen of peripheral vessels. 

Some observers have found an increase also of red cells. 

On the other hand, brief application of cold to the general body sur¬ 
face results in an increased viscosity of the blood owing to the augmenta¬ 
tion of the cellular elements. 

If the application of cold be local, remote effects are still produced. 
These distant effects are of three classes: First, owing to the constriction 
of the blood-vessels locally, the blood is driven into other areas. Thus 
Winternitz demonstrated that a cold hip bath augmented the volume of 
the arm. This may be termed the remote general action. Second, there 
is the symmetrical or intermediate response, that which affects one of a 
pair of structures affects the other: such is seen when, say, the right hand 
is immersed in iced water, the left becomes blanched and cold. So great 
is this action that Thomson states that a thermometer held in the left 
hand shows a fall of 2° to 5° F. under such circumstances, and he records 
a case where, during an operation upon a divided palmar arch, he pro¬ 
duced vascular constriction in the injured hand by immersing the sound 
hand in iced water, and was thus enabled to proceed with his ligaturing 
unembarrassed by hemorrhage. Third, there arise reflex influences upon 
subjacent or remote viscera. In popular medicine this third category is 
well recognized. Girls sometimes foolishly immerse their feet in cold 
water to arrest imminent menstrual flow on the eve of some entertain¬ 
ment. Bleeding from the nose is treated by allowing a cold key to wander 
down the back. More precisely we now apply our treatment to Head’s 
areas in order to insure the localization of the reflex action to the viscus 
which we desire to influence. 

In order to obtain a cold stimulus, what degree of cold must be em¬ 
ployed? The body temperature in the axilla is 98.4° F.; but the average 
temperature of the whole cutaneous surface when clad with customary 
garments is probably about 92° F. (Winternitz). Hence to induce a 
“cold” reaction temperatures sensibly lower than 92° F. must be employed. 

If the cold be slight, the effect does not proceed beyond the stage of 
arteriole constriction, enhanced cardiac and respiratory action, and in¬ 
creased muscle tone. And these consequences are in variable degree 
transient. The vasoconstriction is followed soon by vasodilatation; but 
the beneficial effect upon the heart, and the general musculature is more 
persistent. While in the cold bath, when the cold is mild, or after emerg¬ 
ing, if it be less mild, the cutaneous blood-vessels dilate, the skin reddens, 
a pleasurable sensation of warmth ensues, and a feeling of general well¬ 
being prevails. Such is the “reaction” to the cold bath. To elicit it in 
the sick great care is necessary to temper the stimulus to the patient’s 
strength. The shock produced by the cold must not be too severe. The 
severity is mitigated by careful regulation of the temperature of the 


HYDROTHERAPY 


413 


water, by stimulating the skin either with the impact of myriads of gas 
bubbles produced by aerating the water, or with massage, and by shorten¬ 
ing the duration of the bath. 

Heat. As already stated, the initial effect of all forms of physical 
stimuli is essentially the same; hence the action of heat is not directly 
inverse to that of cold. All stimuli produce initially vasoconstriction, 
but whereas with cold this effect tends to be maintained, with heat it is 
immediately superseded by vasodilatation which persists as long as the 
heat. Owing to the vascular dilatation the skin reddens, a sensation of 
warmth prevails, sweating increases, and the deeper structures are de¬ 
pleted somewhat of their blood. The increase of the cutaneous blood 
sheet promotes radiation, the evaporation of the excess of sweat renders 
latent a vast amount of heat, and the concomitant increased frequency 
of respiration abstracts much heat in the larger volume of expired air 
and water vapor: hence, all these factors tend to cause a fall of tempera¬ 
ture. If the whole body be immersed in a bath of a temperature higher 
than 98.4° F. the body temperature may rise somewhat. 

The relatively anemic condition induced in the viscera minimizes 
their activities and thus heat tends to act as a general sedative. Also, the 
direct action of heat upon the sensory nerves is pleasurable and soothing. 
The sedative influence of heat is invaluable in abolishing convulsive seiz¬ 
ures due to tonic conditions in children. The warm bath is the surest, 
safest, and simplest sedative for the irritable nervous system of infancy. 
The warm bath has now replaced the opiate “strait” jacket and padded 
room treatment of excitement in mental disorders in most modern asylums. 

The effects of heat and of cold on respiration appear to be somewhat 
similar; each produces at first a sharp inspiration; next a pause, and 
then a long expiration which is followed by frequent and shallow 
breathing. 

On the other hand, hot baths diminish the power of muscular work, 
unless at the same time mechanical stimuli such as douches and massage 
are employed; but even with these adjuvants the increase in efficiency is 
always less than under the influence of cold applications. 

Together with the increased muscular effort with which respiration 
is performed, increased production of carbon dioxid and increased absorp¬ 
tion of oxygen occur also. This evidence of increased tissue respiration is 
due to the active katabolism which the tissues are undergoing in their 
effort to produce by combustion sufficient heat to compensate for that 
abstracted by the cold water. The effort is partly of reflex nervous origin 
(cf. the shivering) and partly consequent upon the flooding of the viscera 
by the blood which has been expelled from the constricted cutaneous cir¬ 
culation. Roughly speaking, therefore we may regard the action of cold 
as tonic, of heat as sedative. 

In addition to its use as a medium for applying physical agents, water 


414 


HYDROTHERAPY AND BALNEOLOGY 


is of great service as a solvent. It is the most universal of all solvents, 
the vehicle for the administration of all soluble drugs. 

Water is given to remove in solution or in suspension noxious material, 
not only from the surface of the body, but also from its apertures and the 
cavities into which these apertures open. The bladder, uterus, rectum, 
colon, and stomach are all subject to its cleansing action. 

Water is introduced within the lymph-vascular circulation through the 
mouth and rectum; subcutaneously, intraperitoneally, and intravenously, 
in order to dilute circulating toxins. By making these toxins less concen¬ 
trated, water makes them less poisonous. It is similarly administered in 
cases of shock, particularly shock arising from hemorrhage, in order to 
refill the depleted vascular system and to provide endocardial stimulation 
to the failing heart. These diluting and refilling actions are especially 
valuable in septic conditions, such as forms of scurvy, in which toxemia 
is complicated by profuse hemorrhages from mucous surfaces, and in 
diseases, such as cholera infantum, in which toxemia coexists with pro¬ 
fuse watery alvine discharges. 

Water may be so completely contained in a membrane that no leaking 
or oozing occurs, and salt may be dissolved in the water to the point of 
saturation without impairing the containing power of the membrane. 
But, if a membrane perfectly containing an aqueous solution of salt be 
placed in contact with a weaker aqueous saline solution, or with water 
containing no salt, an interchange takes place through the membrane, so 
that the salt content of the water inside the membrane becomes equal to 
the salt content of the water outside the membrane. Salt diffuses from 
the more to the less salty solution, and water, from the less to the more 
concentrated solution. This diffusion is called osmosis. The more con¬ 
centrated fluid is said to have the higher osmotic pressure, and the diffusion 
ceases when the osmotic pressure on both sides of the separating membrane 
is equal. Osmosis is one of the most important physical processes in life. 
It is a determinant of the movements of all the body fluids and promotes 
the distribution and elimination of the contents of these fluids. Water 
has a lower osmotic pressure than human serum, so, when swallowed, water 
passes through the membranous bowel into the lymph-vascular capillaries. 
Water containing so much saline in solution that it is of higher osmotic 
pressure than the serum causes diffusion of fluid from the lymph- 
vascular capillaries into the bowel lumen. Thus do saline cathartics 
produce copious watery stools. Just as osmosis occurs between the bowel 
contents and the contents of the lymph-vascular capillaries so does it occur 
between the contents of every living cell and the fluid bathing that 
cell. 

The principle of osmosis has been applied by Sir Almroth Wright, 
the distinguished Irish bacteriologist, to the treatment of septic gunshot 
wounds. Antiseptics generally are protoplasmic poisons. The best anti- 


HYDROTHERAPY 


415 


septics are those which are highly destructive to the protoplasm of bacteria 
and relatively harmless to the healthy human cell. 

Antiseptics, however, are almost invariably additional destructive 
agents menacing the life of the damaged cells in a wound. After careful 
observation of the unfortunate effect of antiseptics upon wounds arising 
in modern war, Wright discarded antiseptics in favor of the bland and 
uniformly beneficent saline solution. Saline solutions wash wounds free 
from all uncleanness, exudate, debris and surface organisms; dissolve, 
dilute and disperse toxins, and by osmosis mechanically relieve cells of 
their diffusible noxious contents. The natural resistance of the tissues is 
thus greatly reenforced and the optimal conditions for local repair are 
ensured. The brilliant results already achieved by. Wright with this 
method of treating septic wounds make this new application, of hydro¬ 
therapy one of the most important advances in surgery of our time. 

Mode of Application 

The means employed to apply water are innumerable. Many elaborate 
apparatus have been devised but, in proportion as their complexity 
increases, their usefulness as a rule decreases. Indeed, all the essential 
principles upon which hydrotherapy is based may be utilized through 
primitive domestic appliances. The ordinary full hath, partial baths such 
as hip baths, shower and douche baths, wrapping in wet sheets, and the 
application of compresses are the most important means by which water 
is applied. The temperature is either maintained as constant as is 
possible throughout the procedure, or it is designedly varied. 

The water baths may be medicated in various ways. Salt-water baths 
(one-third of a pound of salt to each gallon of water) ; alkaline baths 
(one-fifth ounce of sodium carbonate or one-tenth ounce potassium car¬ 
bonate per gallon) ; acid baths (one-third ounce dilute nitrohydrochloric 
acid per gallon) ; mustard; bran; aromatic baths, such as lavender and 
pine.; mercurial; ammoniated; sulphurated; and countless other varieties 
are employed. 

The purpose of this medication is to add to the temperature effects, 
bland or irritating, sedative or stimulant action of the medicament. 

Stimulant action is obtained not only by appropriate temperatures 
and medication, but also by suitable regulation of the duration of the 
application. At Nauheim stimulation is enhanced by the impact of hosts 
of bubbles of carbonic acid gas upon the skin. Massage and friction bring 
about a similar but more powerful action. By projecting water at high 
pressure against the body—douches, needle sprays a similar result is 
obtained concomitant with the action of the water. 

Hence, temperature, irritation or sedation and pressure, may all be 
readily applied by means of baths. The practitioner, to employ the 


416 


HYDROTHERAPY AND BALNEOLOGY 


remedial measure satisfactorily, must first clearly recognize the precise 
effects he wishes to attain; then consider what means are most simple, 
most practical, and most certain to procure these effects. There is nothing 
absolute in the facts herein set forth for the use of baths in various condi¬ 
tions. These facts are gleaned from standard authorities such as Winter- 
nitz, Baruch, Schott, and others. They are meant merely as guides to 
treatment. No one slavishly follows the pharmacopeial dose of drugs. 
Each patient is a new experiment. So the temperature, duration, composi¬ 
tion, and frequency of the bath, and the use of pressure, or massage, must 
be as carefully considered and as judiciously altered as the dosage of 
drugs would be. 

The bath may be general, or local, either applied to the entire body 
surface, or only to some part. The water may be brought into direct con¬ 
tact with the skin, or another medium, as a sheet, may be made the vehicle 
for its use. 

General Baths —The Ablution .—An oilcloth or rubber sheet, covered 
with a blanket, upon which is laid a sheet, is prepared on the bed of the 
patient. Each part of the body is consecutively exposed; a wet towel 
wrung out of water is laid on the uncovered area. With the flat of the 
hand rubbing is applied through the towel and then the towel is removed 
and the part dried. When the whole body is to be treated in this way it 
is best to take the parts in definite order. This is the method of 
Winternitz. 

Baruch recommends for much weakened patients the following pro¬ 
cedure : On the day following a warm cleansing bath the patient is 
wrapped in long-haired blankets, one passing around the body, under the 
arms, and inclosing separately the lower extremities; another enfolds the 
arms at the sides, and is tucked in about the neck and under the feet. 
Heat is thus accumulated at the surface. In one-half to one hour the 
face is washed with water at a temperature of 50° F. Next each part is 
in turn bathed, rubbed, dried by gentle friction, and re-covered. 

When the patient has become accustomed to this the ablution may be 
given with the subject standing. He stands in twelve inches of water at 
100° F., the attendant washing him down with his hands or with a towel, 
and pouring on parts of the body water at a temperature initially 80 F., 
but daily lessening till it reaches 60° F. 

Patients unaccustomed to cold water may begin by a partial ablution 
involving only the face, neck, and chest, and gradually including the whole 
body. 

Ablutions should always be rapidly performed. They are useful not 
merely as stimulants of the peripheral nerves and vessels, but also by the 
reaction induced, as an index to the state of the patient. They are much 
employed as a preparation for other forms of hydrotherapeutic treatment. 

The Half Bath .—There should be in the bathtub enough water to im- 


HYDKOTHiEKAPY 


417 


merse the pelvis, and it should be at a temperature of 70° F. to 85° F. 
To prevent retrostasial congestion the patient’s head is wrapped in a cold 
moist towel. The face is first bathed. The attendant then with one hand 
throws water from a vessel over the front of the body, and with the other, 
meanwhile, rubs the back. Colder water is used until the patient feels 
cold; should his teeth chatter he should be immediately taken from the 
bath. A warm dry sheet, previously prepared, is then folded about the 
patient, and with it he is dried. 

Affusions .—Water at a temperature of 50° F. to 65° F. is poured 
from above on the patient, who sits in the empty tub, or lies on a rubber 
cot. The degree of stimulation is in proportion to the temperature of the 
water employed, and the height from which it is allowed to descend upon 
the subject, that is, the lower the temperature, and the greater the height, 
the greater the stimulation. This treatment should be very quickly given. 
In acute cases the patient sits or lies; in chronic cases he stands in water 
at a temperature of 100° F. 

By means of the affusion the sensory cutaneous nerves over a large 
area are mechanically and thermally stimulated, and a reflex action on the 
heart, respiration, and metabolic functions ensues. The intermittent 
nature of the stimulation increases the effect produced. 

Affusions should he used with caution, with precision, as to tempera¬ 
ture, and with due regard to the patient’s power of reaction. 

The Sheet Bath .—A rubber sheet and a blanket are laid on one side 
of the bed, or on an adjoining bed. There should also be in readiness 
several linen sheets, coarse or fine, according to the effect desired, a tub 
of water, a cup, and a sponge. The linen sheet is wrung out of water at 
50° F. to 80° F., spread quickly on the rubber sheet; the patient, whose 
head and face have been bathed in ice water, and whose head has been 
wrapped in a cold wet towel to prevent retrostasial congestion, is laid on 
the sheet. Systematically, small areas of the body in succession are 
warmed by gentle friction. As soon as a part is heated a cup of cold water, 
50° F. to 60° F., is poured on it. This procedure is continued till the 
patient feels cold or shivers markedly. Sometimes the subject is permitted 
to remain in the wet sheet for half an hour; then often a gentle sleep 
follows. The first effect of the cold wet sheet is to contract the peripheral 
vessels; next dilatation of the cutaneous vessels occurs and is aided by the 
friction; the cold water then again contracts them; and so the process 
continues. 

Drip Sheet .—The drip sheet is a modification of the sheet bath. The 
room in which this measure is carried out should have a temperature of 
not less than 70° F. The patient, with a wet towel on his head, stands in 
twelve inches of water at 100° F. A dripping sheet, wet with water at 
75° F., is placed over his shoulders; under the right arm, across the hack, 
over the left shoulder, across the front, and over the right arm. Quick 


418 


HYDROTHERAPY AND BALNEOLOGY 


strokes and occasional slaps are made by the operator up and down over 
the sheet. Twice or thrice during the procedure a basin of water, 10° F. 
or l£° F. colder than the water in which the sheet has been dipped, is 
poured over the head and shoulders of the patient; in the intervals friction 
for five to ten minutes is applied. On removing the sheet—which should 
be rapidly done—the skin is hyperemic. The patient then steps out upon 
a woolen rug or blanket, is completely dried with soft linen towels, .and 
then rubbed down with a warm sheet or towel. If this bath greatly 
fatigues the patient, its duration should be lessened till the reaction and 
resistance are strengthened. 

The strength of stimulation in this measure may be greatly varied 
by varying any one or more of the factors, temperature, friction, the use 
of coarse or fine sheets, the use of the sheet dripping or well wrung out, 
the frequency of the applications of cold water during the process, and 
the duration of the bath. 

If the hands and feet are cold even on arising, it is well to induce 
heat to accumulate before the sheet bath is given, by piling on blankets, 
by giving a w T et pack for one-half to one hour, or by a vapor bath for a 
few minutes. 

The Cold Rub; the Cold Sponge .—On arising, before losing the 
heat of bed, the patient is wrapped in a sheet well wrung out of water, 
temperature 60° E. to 75° F., and is very actively rubbed down, with fre¬ 
quent slapping to produce an active hyperemia of the skin. After rapid 
drying and the administration of a cup of hot milk the patient is sent out 
for a walk. 

The Wet Pack .—A rubber sheet is covered by a large blanket, which 
hangs over one side of the bed and down over its foot. A large coarse 
sheet, very well wrung out of water at 60° F. to 70° F., the temperature 
being varied to suit the case, is spread on the blanket. The patient, his 
head in a wet turban, lies down with upstretched arms; the right side of 
the sheet is brought under the arms across the front of the body, and be¬ 
tween the lower limbs. The left side is brought over the arms and body 
and tucked in at the neck and feet. The blanket is then drawn firmly 
about the patient and tucked in at the sides, neck, and feet. “Everything 
depends upon complete exclusion of air from beneath the blanket cover.” 
If the patient is chilly he should be covered with blankets. Partial packs, 
including only the body below the axillae, may be given. The pack lasts 
one-half to one hour. The effect varies with the duration, the texture of 
the sheet, the temperature of the water, the extent of the pack, and the 
frequency and number of times it is repeated. To restore the tone of 
the cutaneous vessels, which have been relaxed by the wet pack, the half 
bath, the sheet bath, or the cold ablution should follow. In the wet pack 
the reaction is entirely dependent upon the patient’s capacity. If the 
skin be previously warm the reaction is better. The power of the patient 


HYDROTHERAPY 


419 


to react should be tested and educated by other bydrotberapeutic measures 
before wet packs are given. 

In the cold wet pack there is an initial shock lasting from five to 
twenty minutes. This is followed by a byperemic cutaneous reaction. 
There is an interchange between the cooled blood of the peripheral circu¬ 
lation and the warm blood from the viscera, which continues until the 
sheet is thoroughly warm. The excretion of the skin is increased, and 
toxins are eliminated. The wet pack also has a calming effect due to 
withdrawal of blood from the brain and the exclusion of external cutaneous 
stimuli. To secure the antipyretic action the water for the initial pack 
should be 60° F. to 70° F. When the first pack is warm the patient 
should be put into another, wet with water 2° F. warmer. As soon as the 
second pack is warm the procedure may be repeated, raising again the 
temperature of the water employed 2° F. This is done till four or five 
packs have been given, or until the body temperature be satisfactorily 
reduced. If the pack be given for its sedative action and sleep follow 
the patient should be permitted to remain in the pack till he awakes; a 
cold ablution should then be given. 

Hot Blanket Pack .—Three or four blankets are laid on the bed; one 
blanket is wrung out of water as hot as can be borne by the hands, and 
spread on the bed. The patient is folded in this, and covered by the other 
blankets. After a cold wet pack the sheet is warm; but after a hot blanket 
pack the wet blanket is cool, showing that there has been a diminution of 
heat production. 

The Wet Compress .—Almost all forms of the compress consist essen¬ 
tially of a linen basis, which is the vehicle for the application of the 
water, and a dry flannel bandage which covers and secures it. These vary 
only in shape and size to suit the region of the body to which they are to be 
applied, and in the temperature of the water used. 

The cold compress causes contraction of the peripheral vessels, and 
should, therefore, be renewed frequently enough to keep it a cold applica¬ 
tion. When the stimulating compress is employed the water is at 60° F., 
and the compress is permitted to remain in situ till it is warm or even dry. 
When covered with waterproof material the compress becomes a surgical 
wet dressing; astringents or alcohol are often used for wetting. It is so 
difficult to keep water compresses hot, and so inconvenient to handle them, 
that better heat-retaining media, such as the linseed compress, are much 
used. 

If the temperature of the patient be high the compress should be 
changed every half hour; otherwise every hour, night and day, unless the 
patient is asleep. Fresh water should be used, and the compress boiled 
every day to prevent septic infection of the skin. 

The Abdominal Compress .—The linen used for this compress should 
be in three layers, of sufficient width to extend from the xiphoid process 


420 


HYDROTHERAPY AND BALNEOLOGY 


to the symphysis pubis, and fall over the sides of the trunk. The water 
out of which this cloth is wrung should be at a temperature of 60° E. 
to 70° E. 

The Neptune Girdle. —The Neptune girdle is a modification of the 
above compress. The linen is made long enough to encircle the body and 
form a double fold on the abdomen. It is covered by a dry linen or flannel 
binder, and is changed twice or thrice in the twenty-four hours, the part 
being sponged with cold water before each renewal. 

The Combination Compress of Winternitz. —The Neptune girdle is 
applied as described. A Leiter coil, arranged to have hot water passed 
through it, is laid on the epigastrium. This hastens the reaction, and 
reflexly stimulates the nerves of the underlying organs. When a com¬ 
press is employed to reduce inflammation it should be frequently changed, 
never being permitted to become warm. The object here is to keep the 
vessels of the inflamed part in a state of contraction. The temperature 
should not be so low as to paralyze the cutaneous vessels, nor so high as to 
dilate them. To attain the desired end a temperature of 50° E. to 60° F. 
is suitable. 

Cold Applied to the Head. —Instead of using the clumsy ice-bag, 
which wets the pillow, a wet cloth may be laid on the head, and held in 
position by a cap of coiled rubber tubing through which ice water 
flows. 

The Full Bath. —This may he given hot or cold, with or without fric¬ 
tion. The cold full bath has become intimately associated with the name 
of Brand in the therapy of typhoid fever. Brand’s method for the cold 
full friction bath is described later. 

Another form of the cold full bath is the graduated hath of von 
Ziemssen. The patient is placed in a tub which is partially filled with 
water at a temperature of 86° F. to 90° F., and to which water of a tem¬ 
perature of 40° E. is added till a temperature of about 77° F. is attained. 
Friction is used, and the hath lasts one-half hour. The patient, on emerg¬ 
ing, is allowed to remain in warm blankets for fifteen minutes before he 
is dried and dressed. 

Winternitz recommends the employment of alternate half and whole 
cold baths, the former at a temperature of 60° F. to 68° F., the latter at 
a temperature of 42° F. to 50° F. The patient remains in the half bath 
one to two minutes, then steps into the other for one-half to one minute, 
continuing the alternation according to the extent of the desired reaction. 

As a hydriatic measure the cold full hath requires the strongest re¬ 
active response from the patient; it is therefore necessary, especially as 
the reactive power is weakened in the sick, to bring to its aid the friction 
insisted upon by Brand and his followers. 

The Cold Plunge. —This bath should not be entered if the subject feels 
chilly. If necessary the skin should be previously warmed by some other 


HYDROTHERAPY 


421 


procedure, such as the wet pack. The face and neck should first he bathed 
with very cold water, and the plunge bath then entered suddenly. The 
whole body should he immersed in the water, the head also being dipped 
several times. The bather should exercise, or rub himself in the water. 
The plunge bath should last from a few seconds to two or three minutes. 
It should be followed by vigorous rubbing. As soon as dry the patient 
should exercise moderately, or he massaged. 

The Warm Full Bath .—Any hath with a temperature above that of 
the skin (92° F.) Baruch designates a warm bath. 

The temperature of the room in which a warm bath is given should be 
between 70° F. and 80° F. Warm towels and a warm sheet and several 
hot-water hags should be in readiness. If there is no hot water on tap, 
tubs of water at a temperature of 200° F. should he prepared, so that 
the bath temperature may be raised at any time if necessary. The water 
in the hath should have a temperature of 95° F. (Baruch) ; it is also used 
at temperatures between 98° F. and 104° F. The patient wets his face 
and neck with the water in the tub before entering it. He lies down in 
the bath and should remain immersed to the chin. The duration of the 
bath varies with the conditions for which it is administered. Something 
warm should he provided for the patient to step out upon; the warm sheet 
is rapidly folded around him; and he is put into a warm bed and covered 
with blankets. After a few minutes he is dried. Profuse perspiration is 
to be avoided. 

When the bath is warm the irritability of the sensory nerve endings 
is decreased; the bath has therefore a sedative effect. A hot hath—one 
above 100°—has a directly opposite action. 

The Continuous or Hammock Bath .—The ordinary bathtub is usually 
too small for this purpose. So that the patient may be able to repose 
in comfort for a prolonged period he is suspended in a hammocklike 
arrangement, which should clear the bottom of the tub. Suitable rests 
should be provided for the head and nates. If the size of the bathtub 
be adequate, a hammock hath can he easily improvised at home; opposite 
one another, along each of the two sides of a large sheet, four to six 
pieces of stout bandage are stitched. The pieces must be long enough to 
allow, the free ends of any pair to be tied under the bathtub, when the 
middle of the sheet rests upon the bottom of the tub. After the patient 
has been placed in the bath, upon the sheet, the corresponding free ends 
of each pair are pulled until they are so tightened that the part of the 
body which their section of the sheet supports is made to assume the 
optimal position for its comfort. Strips of bandage six inches wide may 
be used and the sheet altogether dispensed with. If the bathtub rests 
directly on the floor, stout wire should he twisted into S-shaped hooks, one 
curve of the S hooks on to the side of the bath ; to the other curve, which 
should be within the bath, the supporting bandage is fixed. An India- 


422 


HYDROTHERAPY AND BALNEOLOGY 


rubber air ring makes a good head rest for the bather. The temperature 
of the water should be 95° F. to 100° F. The water may be changed 
once in twenty-four hours, or a constant inflow and outflow may be 
arranged. Before the patient enters the bath his skin is anointed with 
a fat—lanolin or vaselin—as saturation may cause shriveling and peeling. 
It is desirable to have the tub raised from the floor and covered with 
blankets to exclude air and prevent exposure. A wooden board may be 
placed across the tub to support the blankets, and also to serve as a tray 
for the patient’s meals. The patient may be lifted from the tub to 
evacuate the bowels and bladder, or the urine and feces may be per¬ 
mitted to pass quickly away in the outflow. A patient is kept in the con¬ 
tinuous bath for any length of time, from a few hours to more than a 
year. The continuous warm bath quiets the mental excitement of the mad, 
particularly of maniacs who have cold or cyanotic extremities. Its seda¬ 
tive effect upon convulsive movements in children is remarkable. In 
septic wounds, especially wounds of the bladder and abdomen, it cannot 
be too highly recommended. In septic wounds of the limbs, arm, foot, or 
leg local baths are preferable, for in the hammock bath a B. coli infection 
is soon added to the original sepsis. I have never seen this B. coli infec¬ 
tion assume a menacing form, but it is both unpleasant and undesirable. 
When a septic wound is complicated by fracture of the bones, continuous 
irrigation, or frequently renewed saline compresses are usually preferable 
to baths, for baths necessitate painful and much to be deprecated movement 
of the broken bones. 

Douches .—In the douche a column of water descends from a height. 
There is thus obtained the piechanical action of the pressure of the water 
as well as the effect of its temperature. Many forms of the douche exist. 
The vertical rain douche is a shower bath, in which the water falls from 
a perforated nozzle or rose. The jet or fan douche is a movable arrange¬ 
ment to direct a column of water upon any part. The ascending or 
perineal douche is a spray of water, directed upward, over which the 
patient sits on a stool with a ring-shaped seat. In the circular douche 
the water is directed horizontally inward from circular tiers of perforated 
metal tubing. The Scotch douche, or alternating douche, applies heat and 
cold alternately, either live steam and cold water being alternated or 
warm water being used in place of the steam. Carbon dioxid and hot air 
are also applied by means of douches. As these are measures which are 
mostly practicable in institutions only they will not be further considered 
here. 

Hip or Sitz Bath .—The tub used for this bath is familiar. The tem¬ 
perature of this bath is varied; it may be cold, tepid, warm, or hot. There 
should be enough water to reach to the umbilicus of the patient when 
he is seated in the tub. The patient should be carefully covered to protect 
him from chilling. Friction of the upper part of the body may be added 


HYDROTHERAPY 


423 


to this treatment. The sitz bath acts on the abdominal and pelvic organs 
and vessels, its action depending, as in other forms of baths, on the tem¬ 
perature of the water and on the duration of the bath. Other partial 
baths are the occipital bath, the elbow, the hand, and the foot baths. 

The Elbow Bath .—The elbow is kept in a vessel of running cold water 
for ten to twenty minutes. Hand and foot baths are given in the same 
way, hut the water may be used cold or hot. 

Application of Extreme Temperatures —Steam and Hot-air Baths .— 
These are commonly given in cabinets which inclose the entire body with 
the exception of the head. The head and neck must be cooled during the 
bath. The temperature of the bath, usually 104° F., though possibly 
higher, is attained gradually as the steam enters. The duration of the 
bath varies with the indications, rarely being more than thirty minutes. 
Winternitz has devised a method for a steam hath at home. A wooden 
raftlike frame lies at the bottom of the tub on which the bather is raised 
from the floor of the tub. A continuous flow of hot water gives off steam 
in the tub, which is well covered to prevent its escape. Higher tempera¬ 
tures can be borne in hot air than in steam baths, and in steam than in 
hot water. The bath causes rapid dilation of the cutaneous vessels, fol¬ 
lowed in a few minutes by sweating. To increase the perspiration cold 
water is given to the patient to drink. It is best after the bath to employ 
some cooling hydriatic measure. 

The radiant heat from electric light is utilized to confer temperatures 
of several hundred degrees. These temperatures can be easily tolerated 
for some time, provided the part to be heated is dry and is enveloped in 
wool or other absorbing material so that perspiration may not gather. 
Suitably swathed, a limb can comfortably endure a temperature of 260° 
for half an hour. The apparatus made by Dowsing and by Tyrnauer for 
administering radiant heat is very practical. The ingenious Bergonie 
has utilized the heat developed by interposing resistance in an electric cir¬ 
cuit in such a manner that he can project heat through the tissues, so that 
it converges upon a desired focus in an organ or structure yet does not 
burn the skin. This “diathermia” has already proved of great worth. 
The application of heat generated by electricity will be fully discussed in 
the section dealing with electricity. 

Russian Bath .—The Russian bath is a form of steam bath. 

Irish-Roman Baths. —Irish-Roman baths are hot-air baths, where the 
patient enters a series of rooms filled with air of increasingly higher 
temperature. 

Ice .—The most common way of applying extreme cold is by means 
of the ordinary ice-bag; the use of coiled tubing, the Leiter coil, through 
which ice water is passed, is, however, preferable. The tubing is coiled 
in any form to fit the part to which it is to be applied. The ice cradle 
is an ordinary hospital cradle, placed over the chest, abdomen, or entire 


424 


HYDROTHERAPY AND BALNEOLOGY 


body. The patient is stripped. Ice-bags or pails of ice are hung from the 
pole of the cradle, and the whole covered over with a thin sheet. The 
patient is kept in the ice cradle till his temperature is sufficiently reduced. 
A hot-water bag is kept at his feet to prevent chilling. 

Ice Rub .—The ice rub is given by means of a flattened piece of ice 
in a cloth with which the parts of the body are rubbed in succession. 

Ice Pack .—The patient is stripped, and enveloped in a cold wet sheet. 
An ice-cap is laid on his head, and pieces of ice, carefully swathed, are 
placed at his sides. He is rubbed by the nurse with pieces of ice, as in 
the ice rub. Other methods of using extreme temperatures are the ether 
and ethyl chlorid sprays and the application of carbon dioxid snow. 

General Observations.—Hydrotherapeutic applications are extremely 
valuable agents, but if skill, precision, and judgment be not employed in 
prescribing and in administering them they may cause great injury. 
General cold applications should never be given in states of collapse or 
in exhaustion, if the temperature be subnormal, during a chill, or during 
a hemorrhage. A patient must be warm before he is subjected to general 
cold. When there is any suspicion of reactive weakness, the reactive 
capacity of the patient must be carefully trained by gradually lowering 
the temperature of the water, and by slowly increasing the duration of 
the bath; meanwhile, mechanical stimulation of the skin through aerating 
the water or through friction should be employed. However, in the treat¬ 
ment of tuberculosis Aberg advises the giving of cold full baths without 
preparatory training of the patient. Full baths of high temperature must 
be used with great caution. In arteriosclerosis, renal disease, and cerebral 
hyperemia, during such hot baths cold must be applied to the head to 
prevent the danger of an excessive flow of blood from the stimulated 
body surface to the head (Winternitz’s Retrograde hypostatic conges¬ 
tion”). My mistakes have occurred in the use of hot baths for comatose 
children. Even when the greatest gentleness is used, moving the moribund 
may precipitate death, and the sudden dilatation of the cutaneous capil¬ 
laries which follows immersion in the warm bath may so reduce the endo¬ 
cardial stimulation, in cases where diarrhea or hemorrhage has depleted 
the vascular system, as to cause the heart to stop beating. The hydrothera¬ 
pist has not the protecting secrecy of the operating room. If the end 
comes while the patient is in a bath, the relatives may consider the sanc¬ 
tity of death profaned before their eyes. So it is well in cases of extreme 
exhaustion to use strychnin, transfusion, pituitary extract or other stimu¬ 
lants, before invoking the restorative power of the warm bath. 

Local applications of heat or cold have little influence on general con¬ 
ditions, but we find few contra-indications for them. Local heat should 
not be applied for the aborting of a circumscribed inflammation as it 
raises the temperature of the diseased part, increases the congestion, and 
favors pus formation. Local cold, however, is valuable, for it has the con- 


SPECIAL HYDROTHERAPY 


425 


trary effect to heat. As an analgesic either may serve. Cold is usually 
better in pain from inflammation for it not only diminishes exudation 
and thus spares the inflamed nerves from pressure, but it has an analgesic 
effect on the nerves. Heat is very serviceable in pain caused by nerve 
lesions. Sometimes trial alone can decide which should be used. It 
must he remembered that severe cold too long applied may impair the 
vitality of the tissues. A protecting layer of gauze should intervene be¬ 
tween ice and the skin and the application should be discontinued for at 
least fifteen minutes every hour. 

Although hydrotherapy may exert not merely a palliative but often 
even a curative influence, its habitual use may create a pernicious tendency 
to rely mainly or exclusively upon it. Other forms of therapy—serum, 
drug, dietetic, psychic, physical, and operative—should have unprejudiced 
consideration in the mind of the rational physician, so that the patient’s 
rights may be sacrificed neither to therapeutic habit nor to therapeutic 
bigotry. 


SPECIAL HYDROTHERAPY 

Diseases of the Circulatory System 

The hydrotherapy of circulatory diseases is very simple. Through 
stimulation of the cutaneous nerves by means of cold water charged with 
salts and gas, or turpentine, or ammonia, or other mild irritant, vasocon¬ 
striction is produced in one set of arterioles, and a vasodilatation in 
another. Conceivably also the stimulation reflexly influences the heart 
muscle itself. The vasomotor changes produce endocardial stimulation by 
raising the blood-pressure. But together with the rise there is dilatation 
of the visceral arterioles so that the blood is driven into and through the 
stagnant parts of the circulatory system. The nutrition of organs in 
which stasis is a menace is thus improved. The heart is made regularly, 
mildly, and effectively to act. The coronary capillaries may share in the 
blood redistribution and the heart thus benefit directly from the bath. 
But there is as yet no proof of any special implication of the coronary 
circulation. Doubtless, however, cardiac nutrition is enhanced by the 
steadying and slowing influence of the discreetly increased blood-pressure. 
It is, as it were, a mild and beneficial exercise which the heart enjoys. 
The slowing of the rate and the regular rising of the cardiac rhythm not 
only enables the heart effectively to empty its cavities, but in the pro¬ 
longed diastoles an opportunity for regular and systematic flooding of the 
coronary capillaries occurs, and the nutrition of the heart muscle improves. 

The application of cold to the precordium will slow the rapidity of an 
irritable and infected heart. It is a valuable adjuvant to the treatment 
of endocarditis and pericarditis, as it moderates the fevered activity and 


426 


HYDROTHERAPY AND BALNEOLOGY 


saves the cardiac muscle from undue exhaustion. Moreover, in valvular 
lesions, this tranquilizing of the heart spares the fragile, edematous, 
infiltrated valves from as many impacts as the heats that are avoided. 
Precordial cold applied causes also a dilatation of the vessels in the heart 
muscle and in the pericardium, and thus aids in repelling the bacterial 
invasion by augmenting the blood supply. 

Heat cautiously applied to the precordium may stimulate the heart 
to more forcible, more regular, and more efficient contraction. It, also, 
reflexly, causes a constriction of the coronary vessels. In weak, distended, 
dilated hearts the application of heat may act as a powerful stimulus and 
soon strengthen, regularize, and increase the amplitude of the pulse, and 
diminish the area of cardiac dulness. 

Arteriosclerosis. —It is of great importance to recall the dual relation 
which the increased peripheral resistance maintains in this common 
malady. It serves, not only as a cause, but also as an effect. When 
faulty dilatation of the vessels exists there ensues an imperfect elimination 
of unknown products of metabolism which lead to a toxemia. This in¬ 
crease of circulating toxins mainly by direct action on the vessel walls, 
but perhaps indirectly also, through the vasomotor nerves, gives rise to a 
spasm of the vessels which, in turn, leads to a still more scanty blood flow; 
as elimination is dependent upon the rate of renewal of the blood in the 
emunctory organs, such a decrease in the vascular supply serves to cripple 
depuration still more. Thus a vicious circle is instituted and the toxemia 
increases. The increased resistance to the vascular current in turn places 
added work upon the heart, which at first hypertrophies and later fre¬ 
quently dilates as myocardial changes occur. As, except for temporary 
effect, drugs should not he given to obtain the desired vasodilatation, 
hydriatric measures possess a particular value in the treatment of sclerotic 
vessels. By hydrotherapy it is possible to reduce the undue constriction 
of the vessels, thus to augment the blood flow and to promote elimination. 
The partial rub at a temperature of 68° F. is best suited to be the initial 
measure. If the patient withstands this mild procedure, after a few days, 
more stimulating measures, such as the full cold rub, preferably at a 
lower temperature, should be instituted. The duration of the rub is 
governed by the reaction. The applications of cold to the precordium and 
head are indicated not only to meet the effect of the disease on the cir¬ 
culatory mechanism, but also to counteract the added strain placed thereon 
by diaphoretic measures. The steam bath of moderate duration and tem¬ 
perature, not exceeding 140° F., when used in arteriosclerosis as a dia¬ 
phoretic must be conjoined with cold applied to the precordial region and 
head. The employment of the hot bath, 95° to 100° F., is of great service. 
Venous sluggishness yields often to running foot baths. 

Endocarditis — Acute .—In all cases of acute endocarditis the applica¬ 
tion of cold to the precordium is indicated, as by this measure cardiac 


SPECIAL HYDROTHERAPY 


427 


sedation is secured and the possibility of the occurrence of embolism is 
minimized. The applications of choice are the precordial coil and the 
ice-hag. The selected one should he kept in place continuously for a period 
of, say, several days, unless the heart shows signs of weakness. In the 
presence of non-inflammatory myocardial changes cold precordial applica¬ 
tions must he used with caution or not at all. Partial rubs later in the 
course of the disease are advocated. 

Chronic .—Local stimulation of the heart obtained by the use of the 
cold precordial coil is practiced. It is claimed that digitalis may be sup¬ 
planted by this application. The use of heat to induce general invigora- 
tion and to reduce peripheral resistance is advisable, but only under 
extreme caution, as the temporary increased activity resulting from 
thermic measures may be most potent in producing cardial dilatation. 
Diaphoretic measures, as wet packs, partial rubs, and the Wintemitz 
modified steam bath applied five to ten minutes, are of value in reduction 
of edema. The last consists in exposing to steam the lower parts of the 
body while to the precordium is applied a cold coil to reduce the danger 
of dilatation. Irregular or broken compensation and cardiac insufficiency 
require careful hydriatric management. Much depends upon the changes 
in the heart muscle. The use of the carefully graduated partial ablution 
(68° F.) for several days and then the application of the cold precordial 
coil are the usual treatment. If there be undue vascular constriction 
present in the cardiac insufficiency general measures may be applied to 
eliminate it. Prominent among general measures may be mentioned the 
Nauheim or Schott treatment. 

Hemorrhoids.—This aggravating malady often yields to brief, cold 
sitz baths of about 85° F. temperature. Hot hip baths are valuable to 
relieve pain and to ensure cleanliness and should he given night and 
morning. After every evacuation of the bowels cleanliness should be 
attained by cold sponging. 

Acute Pericarditis.—The ice-hag or cold Leiter coil is applied con¬ 
tinuously to the precordium with the same precaution observed in acute 
endocarditis. . These measures exert decided analgesic and anti-inflam¬ 
matory effects. Hyperpyrexia is treated with extremely cold half baths. 
Diaphoretic measures, particularly the wet pack for two hours, are in¬ 
dicated by an obstinate effusion. 


Diseases of the Respiratory Tract 

Asthma.—A brief application of cold to the nape of the neck effects 
relief in bronchial asthma depending upon nasal conditions. The form 
used may be an affusion, or a douche under ten pounds pressure. 


428 


HYDROTHERAPY AND BALNEOLOGY 


Acute Bronchitis. —A wet pack for two hours, followed by mechanical 
stimulation, should be tried in an attempt to terminate the disease at its 
onset. The cross-pack (Priessnitz) at a temperature of 45° to 55° F., 
renewed every two hours, often lessens the cough and exerts an analgesic 
effect. The Lissauer method of spraying may be employed for its ex¬ 
pectorant influence: after rapid application of a steam spray at 110° to 
125° E., for fifteen seoonds, over the upper part of the trunk, a cold fan 
douche is applied for three to five seconds; a rapid friction rub follows. 
In sixteen cases in which this routine was employed Lissauer obtained 
ready expectoration. The cold Leiter coil to the precordium may he 
needed, particularly in the aged. Hot mustard foot baths are of proven 
value. 

Acute pulmonary affections frequently complicate the exanthemata, 
particularly measles. When in their course, bronchitis or bronchopneu¬ 
monia appears, cold half baths for five minutes at 78.8° to 71.6° E., with 
douching and subsequent gentle mechanical manipulations, are indicated. 
Extremely brief plunges into water at 61° to 54° E., succeeded by strong 
friction, may be used if the case is doing badly. The mustard pack as 
practiced by Herzfeld is very efficient. In this measure flannel applica¬ 
tions are made of one to ten or twenty dilution of oil of mustard which 
has been made according to the directions of the German Pharmacopeia. 
The diluent is equal parts of alcohol and water and the degree of dilution 
depends on the urgency of the case. The application envelops the child 
from the neck to the knees and remains in place until the skin is mark¬ 
edly hyperemic. When the desired cutaneous hyperemia is attained, 
usually in from fifteen to thirty minutes, the child is placed in a wet, 
33 per cent alcohol pack. At the expiration of one-half hour the wet pack 
is supplanted by a dry sheet. This procedure should be repeated every 
twenty-four hours and oftener if the case is very severe. It produces 
its happy results very rapidly. 

Edema of the Lung. —The mustard pack is claimed to be quite efficient 
in pulmonary edema. The application is continued thirty minutes. 

Hyperemia of the Lung. —The hot hath at 106° to 110° F. for ten 
minutes, or the hot bath for five minutes followed by a warm pack, is the 
usual remedial measure employed. The hot mustard foot bath is of value 
to induce sweating. 

Pleurisy. —In acute pleurisy three symptoms are present, cough, dysp¬ 
nea, and pain, which are amenable to hydriatric treatment. The cross¬ 
binder through which passes a cold water coil is the most efficient measure. 
The ice-bag may be used. Wet packs and mechanical stimulation, and 
half-baths, 71.6° to 68° F., are valuable auxiliaries. In event of an effu¬ 
sion steam baths or hot-air baths, lasting ten to fifteen seconds, followed by 
invigorating measures, are employed to induce diaphoresis. The two- 
hourly-changed cross-hinder may aid absorption of an effusion. Should 


SPECIAL HYDROTHERAPY 


429 


respiratory or cardiac embarrassment appear the cold precordial coil is 
indicated. High fever is controlled by wet packs. 

Constitutional and Metabolic Diseases 

Anemia — Chlorosis .—To prevent heat abstraction while obtaining 
energetic stimulation of the nervous system is the hydrotherapeutic aim 
in treatment of chlorosis. To lessen the heat loss, all cold applications 
should follow some heat-retaining measure, such as the warm bath at 
100° E., with room temperature not below 70° F., the dry pack; or, 
without increasing the heat by additional measures, the heat retention 
during the period of sleep may be utilized by applying the invigorating 
procedures upon arising in the morning. 

The choice of the innervating measures is great. Ablutions of 80° F., 
which are lowered two or three degrees daily and combined with mechani¬ 
cal stimulation, rapidly given in the warm bath, frequently give happy 
results. The ablution may also follow the dry pack. Wet packs followed 
by the half bath and rain baths are valuable auxiliaries, when the nerve 
tone has been heightened. Circular and spray douches of two to thirty 
seconds’ duration, with water, first of high temperature, 95° F., and then 
reduced to a temperature as low as 45° F., followed by massage, yield 
excellent results. Hot-air baths of 125° F. to 160° F. should precede the 
use of the douches. 

The following plan of treatment is valuable: Electric light baths for 
fifteen to twenty minutes, then the fan douche at 105° F. with twenty 
pounds pressure for thirty seconds, and then at 70 ° F. for fifteen seconds, 
and a dry rub, followed by one hour of rest. This treatment is repeated 
on alternate days. 

Secondary Anemia .—The general treatment is that prescribed for 
chlorosis. Among the special manifestations of the paucity of the blood 
cells, the cephalalgia, and the coldness of the extremities—particularly the 
feet—may require special measures. The headache responds happily 
to the use of a hot-water coil applied to the neck, and the cold rub con¬ 
fined to the legs. Brief running foot baths are the most efficient measure 
to relieve the coldness of the feet. Cold douches used after a preliminary 
hot application are indicated in anemia of the viscera. They may be 
general, as the Scotch douche, or localized, as the fan douche applied 
to the abdomen. 

Diabetes Insipidus. —Warm or cold half baths and full baths are 
recommended. The half baths possess a special value for neurotic 
children. 

Diabetes Mellitus. —In addition to attaining a strict cutaneous hy¬ 
giene, thus obviating the dangers of cutaneous complications, hydrotherapy 
exercises some remedial power over diabetes, especially that form which 


430 


HYDROTHERAPY AND BALNEOLOGY 


accompanies obesity. Powerful stimulating measures are employed and 
are often preceded by the application of heat. All efforts should be con¬ 
centrated upon the attainment of a vigorous reaction. Improved general 
metabolism and lessened tendency to acidosis are among the beneficial 
results obtained by the use of water. 

The hot air or electric light baths for five to ten minutes, next the 
circular douche, 105° F., for thirty seconds, then continued at 90° F. for 
thirty seconds, and then the jet and fan douche to the entire body, 70° F., 
for twenty seconds, may be employed once every twenty-four hours. The 
temperature of the final water should be gradually reduced until 60° F. 
is reached, and the jet douche pressure should be progressively increased 
, until twenty or thirty pounds is attained. Ten-minute half baths at 
85° F. with vigorous mechanical stimulation while in the tub, preceded 
by wet packs, may be used. The packs should be continued about forty- 
five minutes, and should be, when applied, about 50° F. Brief cold 
plunges and the dripping sheets accompanied by friction may be employed 
at home. 

Exophthalmic Goiter. —Applications of cold, either the Leiter coil or 
ice-bags, to the thyroid gland and the precordium serve to slow the heart. 
Occasionally an ice rub may be needed. Wet packs for the period of one 
hour, combined with the cold Leiter coil to the spine, and followed by 
a half bath, 79° to 75° F., will sometimes allay the tremor and 
palpitation. 

Obesity. —The attempt of hydrotherapeutic measures in treatment of 
obesity is to increase general metabolism and thereby promote oxidation. 
In the presence of fatty myocardial changes the more severe applications 
should be made with caution, or with a cold precordial coil. Diaphoresis 
by means of hot-air baths, electric-light baths, steam baths, full hot baths, 
and packs, of ten to forty minutes’ duration, should be induced. Then 
cold applications in the form of half or full baths, douches, and rubs, 
at between 55° F. and 70° F., should be employed. Frequently an al¬ 
cohol rub concludes the treatment. Hinsdale finds the combination of 
full hot bath and pack superior to that of hot-air bath and douches, and 
cites two hundred and sixteen cases in which this combination was used. 
Of these cases one hundred and sixty-eight gained weight. Together with 
a strict dietary regime and hydro-intervention, muscular exercises should 
be rigidly enforced. Physiologically unfamiliar exercises are the move¬ 
ments of choice. While each case presents peculiarities necessarily en¬ 
tailing modifications in the treatment, the following prescription from 
Hinsdale may be followed as a guide: A full hot bath at 104° F. for 
twelve to eighteen minutes during the first three days. A hot dry pack 
is then applied for the same length of time. A cool spray, about 75° F., 
and an alcohol rub are the final applications. After a short rest of twenty 
minutes long walking exercises are instituted, and massage for one hour 


SPECIAL HYDROTHERAPY 


431 


follows their termination. Some advocate the application of heat only 
to a degree necessary to obtain visible perspiration. 

Podagra. —When gout is found in association with obesity the hydri- 
atric management laid down for that disorder should be installed at once. 
In the more acute forms analgesia with minimization of the articular 
and periarticular effusions may he obtained by the use of brief cold ap¬ 
plications to the affected parts. These may be followed by circular cold 
compresses. To combat the more chronic gout the following treatment 
may be employed: A jet douche of 104° F. under fourteen to eighteen 
pounds pressure is followed by a full bath at 100° to 104° F. The 
patient is then placed in a dry blanket pack for ten to twenty minutes, 
and then given a cool douche. A rapidly administered alcohol rub ends 
the treatment. The indirect douche at a temperature of 98° to 104° F. 
applied under a force of fifteen pounds in a warm bath is also employed. 
Wet packs applied from one to two hours, with a subsequent brief cold 
douche, such as the rain douche, are of value. General diaphoretic meas¬ 
ures, such as the hot-air bath until perspiration is visible, followed by 
gradually lowered pressure douches, are warmly endorsed. The success 
which the spa treatment of gout has met seems to rest in part upon the 
severe hygiene there imposed upon the patients, as the hydriatric values 
of the various waters seem no greater than that employed in the hos¬ 
pitals and sanitaria. 

Chronic Articular Rheumatism. —If in good condition the patient 
should be placed in the hot-air cabinet for ten to fifteen minutes, after 
which the jet douche should he applied, at thirty pounds pressure, if the 
tenderness is not extreme. The hot-air water douche at 110° to 115° F., 
and the cold douche at 80° F., alternating with one another for fifteen 
and thirty-second periods of application respectively, until three or four 
minutes have elapsed, are utilized. Another form of routine treatment 
is as follows: The patient receives a brisk rubbing while in the full 
bath of 102° to 104° F., which is continued eight to ten minutes. Upon 
leaving the hath he is placed in a hot dry blanket pack, in which he 
remains eight to twelve minutes. A five-minute alcohol rub concludes 
the procedure. Later a hot douche, 103° to 104° F., may be given before 
the hath. It should not be applied to the head. Massage and a cool douche 
may be employed after the bath. 

Steam baths and wet packs may be of value. They should be followed 
by low temperature applications, as cold rubs or three to five-minute cold 
half baths. The Scotch douche and circular compresses applied locally 
are most valuable. It is possible by these various procedures to improve 
the circulation of the affected parts, cause absorption of effusions, and 
increase the mobility of the diseased joints. Atrophy of the surrounding 
muscles may he combated by massage or by the use of a very brief cold 
shower hath to the part in question. Faradization of the joints for a 


432 


HYDROTHERAPY AND BALNEOLOGY 


short time, ten to fifteen minutes, enables the patient to withstand greater 
mechanical stimulation. 

Muscular Rheumatism— The most common varieties of muscular 
rheumatism are lumbago, pleurodynia, and torticollis. For these hot dry 
packs, with moderate mechanical stimulation, may be employed with 
happy results. Baruch recommends the use of the hot-air cabinet for five 
to fifteen minutes, followed by the pressure jet douche. The pressure 
should be thirty pounds unless much tenderness he present. Should the 
condition tend toward chronicity, alternating temperature applications 
will prove of value. 

Diseases of Genito-urinary System 

Bladder — Cystitis .—Inflammatory processes of the bladder may be 
treated by prolonged baths and irrigation. The hath is usually given at 
a temperature of 100° E., and is continued for eight hours daily. While 
the bath is given the bladder is continuously irrigated. Hunner reports 
six cases of bladder disease as favorably influenced by this treatment. 
Warm sitz baths, 90° to 96° F., for thirty to sixty minutes, are recom¬ 
mended. The hammock bath at 95° to 100° F., applied hours daily for a 
long period of time, even months, often affords relief. However, the 
inconvenience and the trouble involved are hardly repaid by the results. 

Nocturnal Enuresis .—Affusions at 60° F. and the half bath are 
recommended. Cold rubs and cold plunges at 60.8° to 64.4° F. are of 
value to effect restoration of the lost sphincter tone. If these measures 
are not fruitful, the short cold sitz hath may be tried. 

Kidneys — Acute Nephritis .—Gentle diaphoretic measures are indi¬ 
cated in acute nephritis. Moderate sweating can be secured by the use 
of hot baths, 100° to 108° F., lasting from fifteen to thirty minutes. The 
effect of the baths is prolonged by the use of a dry blanket pack after 
the bath. Moderate diaphoresis is highly desirable, as it places less strain 
on the heart and lessens the danger of uremia due to sudden elimination 
of a large portion of the liquid portion of the blood. Such treatment 
is based upon the assumption that the skin may partly assume the renal 
excretory role. This view is not entertained by many noted scientists, 
who claim the excretory function of the skin is so slight as to he practi¬ 
cally negligible. It may be that the warm baths increase the toxin de¬ 
struction or its modification or its elimination by the kidney and bowel. 
For the nephritis of febrile diseases, particularly that of scarlatina in 
infants and in the extremely young, the warm hath, 100° to 101° F., is 
used; for older children full tub baths at 90° to 100° F., with the child 
in a blanket, render best service. Half baths at 73° to 77° F. combined 
with strong dry rubs are recommended. 

Chronic Nephritis .—The treatment of chronic nephritic conditions 


SPECIAL HYDROTHERAPY 


433 


is mainly diaphoretic. This is particularly true in the cases of inter¬ 
stitial nephritis. As a rule, the diaphoresis is more rigorous than in acute 
nephritis. Hot and cold applications are employed. Of the former 
one may select the hot bath, the steam hath, the hot-air bath, or the 
electric-light bath. Dry heat is less effective than moist. If there he pro¬ 
nounced sclerotic changes in the arteries the baths must be given cau¬ 
tiously. The application of the cold Leiter coil to the precordium will 
quiet the heart during the period of thermic excitation and guard against 
cardiac weakness. The electric-light bath, in thirty-minute applications, 
followed by a blanket pack, has given excellent results in nephritis with 
edema. 

The following measures may he employed in the order given: The 
electric-light bath for ten minutes, followed by a circular douche at 
102° to 106° F., at twelve to fifteen pounds pressure, for thirty to forty 
seconds; then the jet douche at the same temperature and pressure 
applied for thirty to forty seconds; finally, vigorous dry friction. Baths 
at 95° to 100° F. may he used in subacute cases. All these hydro- 
therapeutic measures must be combined with dietetic treatment, especially 
restriction of fluids. 

If the rigid vessels can withstand the initial stimulation caused by 
the shock of cold applications, the cold douche, the cold rub, cold baths, 
and the cold pack may be used. Continuous packs at 70° F. over the 
loins and abdomen, changed every five hours, coupled with baths at the 
same temperature, are highly recommended. 

The effect of hydriatric applications is to increase the percentage of 
urinary solids. This increase may persist for several days after the ap¬ 
plication. The cold measures are most effective in augmenting the volume 
of the urine. 

Uremia .—Hot wet packs applied for thirty-minute intervals every 
four hours, and vapor baths, given by covering hot bricks with wet cloths, 
continued for an hour, are employed. Careful enteroclysis with water 
at a temperature of 110° to 120° F. may he tried when all else fails. 
Eclamptic manifestations sometimes yield to the wet pack at 70° F. 
applied for one hour. Alcohol sweat baths are of value. The withdrawal 
of blood up to one liter should not be delayed. If it be possible to obtain 
a strong reaction, cold in the form of half baths at 68° to 71.6° F. or cold 
wet packs at 70° F. are utilized. 

Prostate and Urethra —Acute Gonorrhea .—Local thermic applica¬ 
tions are recommended in gonorrhea. The usual form employed is im¬ 
mersion in water at a temperature of 105° to 115° F. for ten to fifteen 
minutes three or four times a day. Local cold measures are also endorsed. 

Gonorrheal Arthritis .—See Joint Affections. 

Prostatitis .—Continuous irrigation, as described under cystitis, pos¬ 
sesses special value in relieving prostatic diseases. The water used in 


434 


HYDROTHERAPY AND BALNEOLOGY 


the acute form may be cold, that is, at a temperature of 50° to 53.6° F. 
Care must be exercised to avoid increasing vesical irritation, which is 
often present. Chordee may he greatly relieved by the hot dip bath. 

Salpinx-uterine-ovarian— Amenorrhea. —Amenorrhea is usually ac¬ 
companied by a relatively scanty blood supply to the uterus. Its correc¬ 
tion is usually achieved by hot local applications. Hot sitz baths at a 
temperature of 110° to 114° E., lasting ten to thirty minutes, and the hot 
vaginal douche at 105° to 110° E., are the measures most often utilized. 
Hot full baths may be pressed into service. The benefits accruing from 
the employment of these procedures may be increased by general massage 
in all cases, and in a few specially indicated cases by the kneading of 
the pelvic tissues. Later, measures to increase the systemic tone may 
be adopted. 

Dysmenorrhea. —If spasm of the uterus is found accompanying pain¬ 
ful menstruation, hot applications are efficacious. Those of choice are the 
hot sitz bath before retiring, hot douche, and hot compresses. The range 
of temperature should he from 108° to 115° F. Nauheim baths are 
recommended by Baudler. If the dysmenorrhea is due to faulty nervous 
mechanism, general measures should he instituted to reestablish the normal 
function. 

Chronic Endometritis. —To increase the vascular tone and remove 
the excess of blood a vaginal douche at 108° to 115° E. should he given 
both upon arising and just previous to retiring. One to two and a half 
gallons of water should he used, to which enough salt should be added 
to determine a physiological saline solution. Excellent results are yielded 
by the Nauheim treatment if but little connective tissue overgrowth has 
occurred. Short cold sitz baths at 85° F. may be tried. During ges¬ 
tation, however, the hydriatric measures should he employed with extreme 
caution. 

Menorrhagia. —Of the local applications designed to lessen profuse 
menstruation, the long-continued vaginal irrigation at a temperature of 
120° E. produces excellent results. In addition general and local meas¬ 
ures should he directed against the causal factor. 

Chronic Metritis. —This is rarely found except as an accompaniment 
of endometritis. Nauheim baths are recommended for those .forms due 
to incomplete involution and inflammation. In general, the treatment is 
similar to that of endometritis. 

Acute Salpingitis. —The severe pelvic pain usually present may he 
modified considerably by prolonged vaginal irrigation. Two to three 
gallons of normal salt solution at 110° to 120° F. should he used three 
times daily. Hot abdominal compresses are valuable adjuncts. If severe 
pain yields not to these measures, the ice-hag may he tried. Should 
the condition become chronic, the Nauheim hath will exert a desirable 
sedative effect upon the pelvic circulation. 


SPECIAL HYDROTHERAPY 


435 


Testicle —Epididymitis and Orchitis. —Thick compresses wet in a 
saturated solution of magnesium sulphate at 60° F., renewed every half 
to one hour, lessen the pain and promote absorption of the inflammatory 
exudate. 


Diseases of Gastrointestinal Tract 

Biliary-hepatic— Cholelithiasis. —The chief value of the hydriatic 
measures in the treatment of gall-stones is the relief of the paroxysmal 
pain of the biliary colic. Warm applications render the greatest service. 
The hot-bath pack is highly recommended. This is applied as follows: 
The patient is placed in a bathtub and covered with water at 104° F., 
which is gradually increased to 115° F. The entire bath has a duration 
of five to ten minutes. When the bath is concluded, the patient is wrapped 
in a hot sheet and blankets and allowed to remain for thirty minutes to 
an hour. Then an alcohol mb or affusions at 60° F. are given. Hot water 
may be given by mouth and gastric lavage may be employed. The latter 
has proved effective in obstinate cases. The trunk compress with the hot 
coil often gives relief. 

Hepatic Hyperemia. —Daily cold sitz baths at 46.4° to 50° F., con¬ 
tinued for five to ten minutes, and cold shower baths combined with cold 
movable fan douches to the skin over the liver often succeed in diverting 
the blood supply to the superficial tissues. The venous stagnation so 
frequently found in the liver is usually a manifestation of cardiac or 
pulmonary trouble, and is relieved by measures directed toward the im¬ 
provement of the heart and lungs. 

Enteric Diseases— Constipation. —Constipation arising in the absence 
of organic disease is related to an atonic or spastic condition of the in¬ 
testinal musculature. It is of highest importance to distinguish between 
these two forms, as the hydrotherapeutic management of each is radically 
different. 

In the atonic form, general measures to invigorate and tone the faulty 
muscle should be employed. In patients of good physique cold may be 
applied at once, as a compress or douche. In the less heroic warmth 
to the point of perspiration is required prior to the administration of 
the cold applications. For atony one may proceed by applying the hot¬ 
air bath or electric-light bath until moderate diaphoresis is induced. 
This is followed by the circular douche at 95° to 105° F., under fifteen 
to twenty pounds pressure, for one minute. The Scotch douche, with 
one-quarter inch nozzle and fifteen to twenty-pound pressure, is applied 
over the colon at 60° and 112° F. for fifteen-second intervals. A fan 
douche at 75° F. and twenty pounds pressure, for ten seconds, to the 
back, abdomen, and chest, and massage to the abdomen with particu¬ 
lar application to the colon, end the prescription. An open-air walk 


HYDROTHERAPY AND BALNEOLOGY 


436 


augments the effects of the treatment. Irrigations of cold water at 64.4° 
to 71.6° F., beginning with small amounts and later increasing to one quart, 
are of value. The cold rub, followed by a brief cold sitz bath of not over 
five minutes in duration, exerts a particularly happy effect upon the en¬ 
teric neuromuscular mechanism. 

The spastic variety of costiveness requires relaxation measures. Warm 
or hot applications are more efficacious than is cold in effecting this 
desired relaxation and sedation. Warm or hot sitz baths at 104° to 
110° E. for twenty minutes, hot compresses to the abdomen, brief warm 
douches, and irrigation of water at 104° F. are the measures of choice. 
Carefully graduated cold enemata administered upon awakening have been 
advocated. 

Diarrhea .—If purging be due to dietetic errors, the removal of the 
irritant material is imperative. This can be accomplished by cold hip 
baths, 50° to 64° F., applied from one to five minutes. Irrigations are 
also of service. Should undue peristaltic activity be the cause of the 
diarrhea, hot sitz baths at 100° F. given from thirty minutes to one hour, 
the hot coil placed over the stomach in conjunction with a wet compress, 
and half baths at 100° F. are the indicated measures. The symptomatic 
diarrhea of catarrhal inflammation of the intestine disappears when the 
hyperemia, hypersecretion, and hypermotility are reduced to normal. 
This reduction may be realized by the intervention of moderately pro¬ 
longed cold measures. 

One routine plan is a cold rub, followed, without drying the skin, by 
a sitz bath at 50° F., for ten to thirty minutes. The abdomen receives 
a strong rubbing during the sitz bath. When the bath is ended an ab¬ 
dominal binder is put in place and replaced when quite dry. Another 
prescription begins with the hot-air bath until the skin is hyperemic. 
This is followed by a wet sheet rub and a simultaneous hip bath at 
70° F., and a foot bath at 110° F., for ten minutes. This may be given 
daily with gradual decrease in temperature of the hip bath to 50° F. 
The hammock bath at 95° to 100° F. often has a benign influence. 

Acute Enteritis .—After the contents of the intestines have been ex¬ 
pelled, the severe pain and the diarrhea may be lessened by hot applica¬ 
tions. Should chronicity develop, the half bath at 70° F. reenforced by 
the repeated pail-pour seems favorably to influence the course of the 
disease. 

Acute Appendicitis .—The use of cold, as a cold coil, the ice-bag, or 
an ice poultice, prior to operative interference lessens pain, emesis, and 
singultus. Gauze should intervene between the skin and the ice to mini¬ 
mize the danger of gangrene. 

General Diffuse Peritonitis .—The treatment here is identical with 
that of appendicitis. Should proctoclysis be adopted, it should be very 
gentle. 


SPECIAL HYDROTHERAPY 


437 


Gastric Diseases —Atony of Stomach. —Brief cold applications, en¬ 
hanced by kneading the abdomen, partially restore the lost tone and im¬ 
prove the sluggish circulation. The cold rub followed by a short cold 
hip bath may be used. The hot-air bath or warm bath to induce visible 
sweating, by a jet or fan douche at 60° F., applied to the abdomen for ten 
to thirty seconds, is productive of benefit. 

Acute Gastric Catarrh. —Hyperemesis yields, as a rule, to ice water 
or ice. The abdominal binder renewed every three or four hours may be 
employed. If high fever arises, general heat-reducing measures are 
indicated. 

Chronic Gastritis. —If atony and dilatation of the stomach are asso¬ 
ciated with this disease they should be combated by 'the appropriate meas¬ 
ures. The gastritis is treated by the half bath at 70° E., concluded by 
the pail-pour, repeated several times. Lavage often renders sturdy service 
in ridding the stomach of thick tenacious mucus. General invigorating 
treatment should be instituted. A cold rub upon arising, with subse¬ 
quent vigorous mechanical stimulation and exercise, is followed by the 
jet and fan douche at 80° F. This temperature may be gradually low¬ 
ered in the later applications, which should occur once every twenty-four 
hours. This treatment has proved very efficient. 

Gastroptosis. —After a hot bath at 105° E. for five minutes, late in 
the forenoon, a spinal douche at 100° to 102° F. of twenty pounds pressure 
is applied for ten seconds. Then the patient returns to bed, and the 
abdomen, particularly the epigastrium, is well covered by a hot wet flan¬ 
nel compress, which is heated by an electric pad and renewed two-hourly. 
An elastic binder tightly encases all. This prescription is recommended 
by Lockwood. 

Dilatation of the Stomach. —This morbid state is usually found in 
conjunction with atony, and its treatment is practically that of atony. 
Lavage of the intestines and irrigation possess special value in this 
disorder. 

Nervous Dyspepsia. —The hot-air bath at 160° to 170° F. for six 
minutes, succeeded by a five-minute friction tub bath at 98° F.; then by 
the rain douche of twenty pounds pressure at 95° F., gradually lowered 
to 90° F.; and then by the spray douche at 80° F. for five seconds followed 
by mechanical stimulation, has given excellent results in the hands of 
Baruch. The jet and fan douches may be used with the temperature 
daily decreased. 

Cold sitz baths at 50° to 60° F., lasting from three to eight minutes, 
cold sheet rubs at 53° to 64° F. upon arising, and brief cold shower baths 
are of service. The malady is very resistant to treatment. 

Ulcer of the Stomach. —To promote a greater blood supply to the 
stomach is one of the initial remedial steps in treatment of ulcer. The 
cold sitz bath at 50° to 54° F. for three to five minutes and trunk com- 


438 


HYDROTHERAPY AND BALNEOLOGY 


presses combined with a brief application of the hot coil to the abdomen 
serve further to increase the blood flow. In addition, the last measure 
increases the alkalinity of the blood (Buxbaum). Cold compresses to the 
stomach are of service. To control hemorrhage one may place ice water 
or ice in the rectum and apply the cold stomach coil. The latter serves 
more efficiently when combined with the cold stomach compress. A strict 
dietary regime must be used in conjunction with the hydriatric measures. 

As gastric ulcer frequently occurs in chlorotics, prophylactic treat¬ 
ment should be instituted in all cases of chlorosis. Cold sitz baths at 
46° to 57° F., for three to five minutes daily, abdominal packs renewed 
every three hours, with a fifteen-minute application of the abdominal 
coil at 104° F. once a day, are the measures often employed. A cold 
pack for twenty to thirty minutes, followed by half bath at 70° E. for 
two minutes, is of value. The pain is relieved by the application of the 
electric pad to the epigastrium. 

Specific Infectious Diseases 

Although control of the body temperature is the cardinal aim of 
hydro therapeutic measures in the treatment of acute febrile disease, 
other manifestations of the toxemia—the rapid heart, the lessened blood 
flow, the quickened shallow respiration, and the emesis—are as cogent 
in their claims as the fever. The altered metabolism as indicated by 
the increase in the urinary ammonia, nitrogen, and the decrease in the 
urea nitrogen, the lessened alkalinity of the blood, and the alteration 
of the morphological elements of the circulatory fluids also claim atten¬ 
tion. Hydriatric measures are able to exert a beneficial influence upon 
all these abnormal expressions. The applications in vogue are the partial 
ablution, the half bath, the full bath, the continuous bath, the hammock 
bath, the Brand bath, the wet pack, the cold rub, the trunk compress, 
and cold applications over the precordium and to the head. 

Diphtheria.—The wet pack changed at uniform intervals, with the 
final application continued until visible perspiration appears, and then 
followed by a bath at 75° to 82° F., combined with vigorous affusions, 
yields happy results. Ice finely subdivided applied in bags to the throat 
often modifies the disease. 

Influenza.—Hot baths are recommended. Sheet baths may be effec¬ 
tual in increasing the systemic tone. 

Exanthemata— Measles .—Full baths at 103° to 107° F., lasting from 
three to six minutes, according to the age of the child, given five or six 
times daily, have met with wonderful success according to their sponsor, 
Dr. Grosse. As the disease is developing, baths at 95° to 100° F. are 
frequently employed. Many merely sponge with cold water, especially 
if there be hyperpyrexia. Brief plunges into water at 55° to 60° F. often 


SPECIAL HYDROTHERAPY 439 

influence the extreme cases. Pulmonary complications are considered 
later. 

Scarlatina .—The remedial value of hydrotherapy in scarlet fever is 
manifest in the decreased death-rate, the low percentage of complications, 
and the lessened period of infectivity of the disease. The applications 
may be either hot or cold. Warm or tepid sponging is applied twice 
daily in ordinary cases. The warm bath at 90° to 98° E. given once in 
twenty-four hours is also effectual in cases of moderate severity. In 
desperate cases baths at 90° F., of five to ten minutes’ duration, repeated 
every four hours, are very efficient in alleviating the symptoms. Han¬ 
som cites three characteristic cases in which these applications were 
of demonstrable value. The hot bath at 98° to 104° E., or hot-air bath, 
is employed to relieve anuresis. Dry packs may be subsequently applied. 
Although a temperature of 103° F. is the indication for the application 
of cold, undue depression, tachycardia, and insomnia also demand it. 
The Kerley graduated cool pack, made of Turkish toweling, applied to 
the torso, and kept in place until the temperature is 102° F., is a valuable 
measure. The initial temperature is 90° F.; by reductions of five 
degrees every five minutes 80° F. is reached, at which figure the tem¬ 
perature is kept thirty minutes. At the expiration of that time, if the 
fever is not perceptibly diminished, the temperature of the pack is re¬ 
duced to 70° F. or 60° F. Partial ablutions at 72° to 80° F. of a 
duration dependent upon the readiness of the reactive response may be 
employed. In the early stages, affusions at 50° to 70° F., following five 
to ten-minute full bath at 105° F., often relieve an embarrassed heart. 
The pyrexia may be reduced by graduated ablutions, which are instituted 
with a temperature of 90° F., and with each administration reduced one 
degree until 75° F. is reached. The wet pack may be employed. In a 
series of one hundred and ten cases treated by cool applications not one 
case of nephritis developed. Angina and adenitis are treated by cold 
compresses. 

Syphilis.—Some increase in elimination of toxic materials is caused 
by the diaphoresis induced by the steam cabinet bath. Sweating may be 
also provoked by the dry pack. These processes offer no interference 
to the cutaneous absorption of mercury. On the contrary, they seem to 
enhance it. General stimulating measures are employed to increase the 
systemic vigor and offset the general effect of the circulating poison. Of 
these the cold shower bath following a one-hour application of the wet 
pack is quite effective. This procedure, however, should not extend over 
five days. The beneficial results obtained at such spas as Mt. Clemens 
and Hot Springs depend more upon the strict mercurial treatment ad¬ 
ministered than upon the chemical properties of the various waters used 
in bathing. The value of the bath lies in the extreme cleansing of the 
epidermis which leads naturally to a more rapid and thorough absorp- 


440 


HYDROTHERAPY AND BALNEOLOGY 


tion of the mercury. It is claimed that the waters of Aix-les-Bains, by 
the virtue of their calcium sulphid content, exert, when applied exter¬ 
nally and internally, a partial curative effect in lues. 

Tetanus.—The application of heat yields the better results, although 
cold measures have been the more employed. Of the warm applications 
the hot wet pack of 100° to 110° F. and the warm bath are most effective. 
Combined with antitetanic serum, they help to oppose the advance of the 
disease. 

Pulmonary Tuberculosis.—Prophylactic treatment of tuberculosis af¬ 
fords a valuable field for the practice of hydrotherapy. The establish¬ 
ment of thorough prophylaxis is sometimes designated “hardening.” It 
should he commenced early in those suspected of a tubercular predisposi¬ 
tion. It is instituted by gradually lowering the morning bath to 86° E. 
The hath should seldom exceed ten minutes in duration, and when ended 
a cold affusion of 70° F. should be given, and then brisk friction applied. 
Older children may be immersed in water at 80° F. for one to four min¬ 
utes, and rubbed vigorously while in the hath. Undue heat loss is avoided 
by making the application in the morning. Exposure to sunlight and 
artificial or natural sea bathing often serve to increase the general 
resistance. 

When the disease has developed, cold sponging with ordinary tap 
water, practiced each morning, is valuable. Poor circulation is a contra¬ 
indication to this procedure. The chest compress and the cross-binder 
applied for long periods of time are useful remedial adjuncts in con¬ 
trolling pain, faulty respiration, expectoration, and cough. They also 
exert a favorable influence on the course of the disease, stimulating the 
encapsulation of infective foci and enhancing the absorption of caseous 
or necrotic tissue. This is probably due to increased pulmonary blood 
flow. 

The Cornet method of hydriatric routine may he employed: The pa¬ 
tient receives, at first, simple friction morning and night, until a strong 
reaction appears. After one week of this, friction is made with a cloth 
wet with water at a temperature of 92° F. This temperature is grad¬ 
ually decreased to 66° F. in the course of several treatments. One-half 
hour of rest is enforced at the end of the treatment. If this treatment 
has been tolerated well, two-minute rubs in a sheet wet with 5 per cent 
salt solution, at 90° F., are inaugurated. The brine is made more cold 
each day until 60° F. is reached. An open-air walk for one hour fol¬ 
lows the treatment. Douches at 90° to 95° F. may be used, except when 
copious expectoration or increased nervous excitability is present. It is 
possible so to adapt patients to cold measures that they take douches 
of tap water at a temperature of 40° F. during the winter, and appar¬ 
ently suffer no inconvenience. Another method consists in beginning 
ablutions at moderate temperature, 95° F., and gradually reducing the 


SPECIAL HYDROTHERAPY 


441 


temperature daily, until 60° F. is reached. Then the ablution is sup¬ 
planted by an effusion at 90° F., which in turn passes through the de¬ 
scending steps until 50° F. is obtained. The affusion is practiced daily. 
Four basins full of water are used at each treatment. 

In the presence of fever all violent measures are contra-indicated. 
The cool sponge bath usually controls the fever, but if it fails, ice rubs 
should be tried. Hemorrhage is met by ice-bags or the cold Leiter coil 
to the thorax and the thighs. 

Yellow Fever.—Diaphoresis by means of the blanket pack should be 
induced. In the beginning of the disease hot foot baths at 105° to 110° F. 
may be tried. 

Asiatic Cholera.—A cold rub in a sheet completely or partly wrung 
from water at 45° to 50° F., or a half bath for two to five minutes at 68° 
to 80° F., often prevents the appearance of diarrhea. Early enteroclysis 
with warm water often relieves the spasm of the intestine. A cold rub 
in a sheet at 32° F., followed by a sitz bath at 8° to 12° F. for fifteen to 
thirty minutes, may check purging and favorably influence vomiting. Ice- 
cooled water applied as rubs and sitz baths is indicated when the disease 
is very severe. 

Cholera Infantum.—Cold baths are not advisable. The happiest re¬ 
sults follow the use of baths, 98° to 100° F., given frequently for intervals 
of five to ten minutes. The addition of mustard to the bath will en¬ 
hance the benefits accruing therefrom. Care must be taken, however, to 
protect the eyes from the irritation of the mustard and also from the 
infective agent of the disease. If convulsions appear or collapse or low 
temperature ensue, heat, either by the hot bath or incubator, or both com¬ 
bined, should be at once applied. The following methods taken from 
Budin-Maloney will prove of use to combat collapse, convulsions, and 
low temperature: 

“Two methods of giving the hot bath may be followed. In one, the 
infant, having, let us say, a rectal temperature of 83.2° F., is plunged 
into water at 100.4° F. and left there fifteen to twenty minutes. The 
rectal temperature is then found to rise to progressively 95°, 96.8°, 
98.6°, and 99.5° F. The infant is then taken out of the bath and placed 
in an incubator, and the rectal temperature taken several times to find 
the duration of the action of the hot water. 

“In the other form of administration the infant is immersed sud¬ 
denly in water which has a temperature one degree higher than that of 
the body, 95° F. in this case. The temperature of the water is then 
gently increased until it reaches 100.4° F. while the temperature of the 
infant gradually rises to 99.5° F. After twenty minutes it is placed in 
an incubator. It is found that the temperature in the latter case remains 
nearer the normal, and falls slower than in the former.” 


442 


HYDROTHERAPY AND BALNEOLOGY 


Dysentery.—The form of this disease caused by amebic invasion of 
the intestine is treated successfully by cold enteroclysis with water at 
40° F. or even ice-cold. The fluid should be administered gently in 
order to obviate pain. Ice suppositories may be tried in the bacillary 
variety. The careful introduction of warm saline solution into the colon 
after defecation is effective in controlling pain and diarrhea. 

Typhoid Fever.—The best results of hydrotherapeutic management of 
enteric fever are obtained when the treatment is instituted at the onset 
of the disease. As a rule, the cold applications are employed, and of 
these the Brand bath enjoys most favor. While with some authorities it 
has been partly supplanted by less heroic measures, accumulated statis¬ 
tical evidence attests its efficiency. It is given as follows: A portable 
tub is placed by the bed and two-thirds filled with water at 70° F. An 
ounce of wine or a spoonful of alcohol is given twenty to thirty minutes 
before the bath, or four ounces of hot coffee may be administered just be¬ 
fore immersion. After wetting the face with ice water, the patient is 
placed in the tub and the entire cutaneous surface mechanically stim¬ 
ulated by a sponge. The initial shock and the feeling of coldness usually 
incite desire in the patient to quit the bath, but in absence of symptoms 
of collapse or marked shivering, immersion should continue for fifteen 
minutes. Twice during the bath one-half gallon of water at 50° F. should 
be poured over the shoulders and head. A slow pulse of small volume 
does not indicate withdrawal from the bath. At the expiration of fif¬ 
teen minutes the patient is wrapped in a sheet and blanket, placed on 
the bed, and, if his temperature exceeded 103.5° F., evaporation is per¬ 
mitted In order to increase heat loss. If shivering be extreme the skin 
is dried and he is returned at once to bed. Artificial heat is undesirable, 
but may be needed to insure reaction, although vigorous rubbing and 
curtailing the length of the next bath are superior methods of furthering 
the reactive powers. Four to six ounces of ice water are given twenty 
to thirty minutes after the bath, and an abdominal compress at 60° F., 
renewable hourly, is applied. The bath is repeated every three hours 
or oftener if indicated. A temperature exceeding 102.5° F., a low mut¬ 
tering delirium, extreme muscular twitching, insomnia, and other mani¬ 
festations of toxemia demand immediate bathing. The total number of 
baths is variable; as many as one hundred and seventy-five have been 
given to one patient. The wonderful results of the Brand bath are shown 
by the 50 per cent reduction of mortality from typhoid recorded by Dr. 
Thompson from New York hospitals. In Australia, of nineteen hun¬ 
dred and twenty-three cases so treated, only 7 per cent died (Hare). 

Various modifications of the Brand bath have been offered. Affusions 
at 70° F., gradually lowered to 60° F., are endorsed by Cabot. The 
hammock bath at 88° F., in which the patient is kept until the tempera¬ 
ture taken per rectum is 100° F., whereupon the bath is omitted for two 


SPECIAL HYDROTHERAPY 


443 


hours or until the temperature again mounts to 102.5° F., seems to be 
nearly as efficacious as the cold bath. The cold bath may be abbreviated 
from eight to five minutes and employed every three hours when a poor 
reaction results. As the recuperative powers increase, the duration of 
the bath is prolonged to fifteen minutes. The partial ablution is used 
also to test the reaction. The general effect of these modified baths is 
not equal to that of the original measure. 

As mentioned above, some medical men regard the cold bath as too 
severe, and have devised substitutes entailing less distress to the patient. 
The ice rub, which is the strong application of a flat piece of ice to all 
of the body except head and neck, exposing only the part worked upon 
at a time, is warmly endorsed by Hare. A fall of two degrees in tem¬ 
perature and a slowing of the heart usually result from ice rubs; spong¬ 
ing with cold water is claimed to be effective in cases in which the tem¬ 
perature is not over 101° to 102° F. The graduated bath beginning at 
95° F. and closing at 80° F. is employed. Full warm baths at 88° F. 
shortened the course of the disease and reduced the mortality from 10 to 
8.5 per cent, according to Riess, who has employed this measure in eight 
hundred and nine cases. A temperature of 102° F. requires the tub for 
five to ten hours until the rectal temperature is 100° F. It seems, how¬ 
ever, the substitutes fail to equal in efficacy the Brand bath. The sta¬ 
tistics concerning these modifications are incomplete, but yet they indicate 
a higher death-rate than follows the use of the Brand method. 

Hemorrhage is met by rest and cold abdominal applications. Ice 
may be used with due precautions against gangrene. 

Malaria.—All applications should anticipate the paroxysm, for once 
the chill begins it cannot be checked. Abortive treatment is efficient. A 
cold douche at 60° F. under twenty to thirty pounds pressure to the 
back for five minutes, with a simultaneous hot foot bath, has proved a 
valuable routine prescription. Cold hip baths and cold douches have 
cured malaria of several years’ standing after arsenic and quinin had 
failed. Two hundred and seventy-two reported cases have yielded to 
hydrotherapy alone. The following prescription is effective: A hot-air 
bath is given for five to ten minutes about one hour before the chill. 
Then a douche or affusion at 60° F. is applied over the spine, spleen, and 
liver from thirty seconds to a minute. The douche should be used at a 
pressure of from twenty to thirty pounds. While the douche is applied 
a hot foot bath at 100° F. should be given. These may be prescribed 
again in one-half an hour and two applications preceding the chill are 
usually able to prevent its appearance. Should a seizure appear a wet 
pack at 65° F. is useful in reducing the temperature and promoting 
elimination. 

Cerebrospinal Meningitis.—Cold applications, such as the ice-bag or 
Leiter coil, to the head and back of the neck are indicated. Hot baths at 


444 


HYDROTHERAPY AND BALNEOLOGY 


104° F. for twenty to forty minutes, repeated four times daily, lessen, 
the pain, spasm, and tenderness and may modify the disease. Early com¬ 
mencement of the treatment is of prime importance. In one series of 
fifty-one cases treated by hot baths the death-rate was 33 per cent. 
The hammock bath at 93° to 100° E. may be tried. The following 
routine is the method of applying the hot bath: The patient enters a 
cushioned bath at 90° to 93° E., which is then slowly raised to 104° F. 
After twenty to forty minutes have elapsed he is lifted out by means of a 
sheet, if much pain be present, and then covered by a blanket. This pro¬ 
cedure is also applicable to the meningismus of children. If tenderness 
be extreme the patient should always be moved bodily on a sheet. As a 
result of the bath the tenderness diminishes, the temperature falls, the 
restlessness and spasm decrease, and the patient sleeps. 

Pneumonia.—Cold applications are selected to treat pneumonia. These 
may be the ice-bag, the cold Leiter coil, the Brand bath, half bath. The 
ice-bag and coil are placed on the chest and on the head. The reduction 
of the toxemia with strengthening of the heart’s action and of the ves¬ 
sel tone is the desired aim of the treatment. The beneficial results of 
cold hydriatric treatment are illustrated by a death-rate of about 3 per 
cent in the report of five hundred cases managed by cold applications. 
Chest compresses and cross-binders are valued measures. Alcohol given 
before and after a bath often averts cardiac weakness. The treatment for 
adults is the Brand bath, the details of which were discussed under 
typhoid fever. The chest compresses wet with ice water and renewed 
when dry or warm, or even every ten to twenty minutes, are valuable meas¬ 
ures. The half bath at 65° to 72° F., of five minutes’ duration, coupled 
with vigorous rubbing and affusions at 50° F., is also effective. The ice- 
bag should be applied over gauze to the thorax and base of head. An 
abundance of plain water should be administered, by mouth, if possible. 
A hot mustard foot bath under blankets, to which hot water is continuously 
added, maintained for forty minutes, is valuable for the diaphoresis it in¬ 
duces. In the aged, adipose, and intemperate the heart must be given 
careful attention. 

In children the cool wet pack and sponging give excellent results. 
Compresses from 75° to 80° F., enveloping the child from the base of 
the neck to the navel, are also used. 

Diseases of the Nervous System 

Cerebral Anemia.—This may be either a symptom of organic change 
in the brain or a manifestation of morbid processes elsewhere. In either 
case the underlying disorder should be determined and should be met 
with the appropriate treatment. The anemia may be combated by pro¬ 
fuse sprinkling of the face and chest with cold water at 75° F. 


SPECIAL HYDKOTHERAPY 


445 


Cerebral Hemorrhage.—The application of an ice-bag or cap or the 
cold Leiter coil to the head, combined with the compresses to the trunk, 
are the customary hydrotherapeutic measures in treatment of hemorrhage 
of the brain. 

Cerebral Hyperemia.—As this condition usually manifests itself by 
marked sleeplessness, measures which afford relief for insomnia may be 
effective in lessening the cerebral blood supply. Douche applications to 
the spine, coupled with strong friction, and cold measures to the head 
and the wet pack applied from thirty minutes to one hour are the means 
usually selected to secure the desired effect. 

Chorea.—In event of heart complications the precordial coil should 
be applied. Full baths at a temperature from 90° to 98° F., and not 
allowed to fall below 80° F., during the bath of one hour’s duration, 
should be given once daily. At the conclusion of the bath the extremities 
are gently kneaded. Wet packs applied from one to one and one-half hours 
in conjunction with the precordial coil exert a decided calmative effect. 
The coil should be applied intermittently at thirty-minute intervals. A 
half bath at 86° F. for five to ten minutes should follow the application 
of the wet packs. A few treatments have effected complete cure in some 
cases. 

Epilepsy.—Hydrotherapeutic measures exert a twofold effect in the 
treatment of epilepsy. They hinder the progress of the disease and re¬ 
enforce the action of drugs. Thus, with the aid of hydrotherapy, convul¬ 
sions may be averted or lessened in severity by smaller doses of bromids 
and the unpleasant condition known as bromism may be avoided. Half 
baths at a temperature from 80° to 86° F., lasting from eight 
to fifteen minutes, and sitz baths at 85° F., show valuable effects. 
The baths may be followed by affusions and Intense rubbing. In 
the young and robust, baths at 75° F., gradually lowered to 68° 
F., and of a few minutes’ duration, are highly recommended by Bins- 
wanger. Hydriatic measures are ineffectual to check a seizure once it is 
firmly established. 

Headache.—Headache is often caused, or accompanied, by cortical 
hyperemia, so the diversion of the blood flow from the brain and the cord 
to the superficial vessels is indicated. This may be accomplished by the 
hot foot bath in water at 95° to 100° F., lasting ten minutes. A cold 
foot bath, 45° to 50° F., of two minutes’ duration, followed by strong 
friction, is equally as potent. Cold compresses changed hourly should be 
applied to the head. The cephalalgia so frequently a symptom of brain 
neoplasm may often be lessened by hot mustard foot baths and hot com¬ 
presses applied to the spine. 

Hemicrania.—This obstinate malady sometimes yields to wet packs 
applied from one to one and one-half hours and followed by cold rubs. The 
drip sheet is recommended. Mechanical manipulation and friction, pre- 


446 


HYDROTHERAPY AND BALNEOLOGY 


ceded by diaphoresis induced by the hot-air bath or any general measure, 
may be useful. 

Hysteria.—The treatment is mainly symptomatic. Pain and increased 
sensitivity yield to long-continued cold applications. The cold compress 
of 65° E. may be used. The cold jet douche with an initial temperature 
of 80° F., gradually decreased to 40° F., applied for one minute, is 
very effective in diminishing sensory excitability. Anesthesia usually 
yields to the same applications. An ice rub is often an excellent remedy. 

The cold Leiter coil to the spine most admirably controls extravagant 
motor activities, such as cough, respiratory spasm, and hiccough. A 
cold water spray of 50° F. or a brief cold douche at the same temperature 
allays the respiratory excitement, while the troublesome hiccough is 
arrested by the application of an abdominal binder in conjunction with 
a hot abdominal coil. Contractures, if recent, often are alleviated and 
removed by the use of the hot coil or full hot baths at 104° to 110° F.; 
if long established, wet packs continued for one to two hours may be tried. 
Muscular atrophy is best combated by mechanical kneading. If paralyses 
exist, brief cold measures are indicated to improve the errant innervation. 
The cold rub at 60° F., the cold half bath at 65° F., and cold brief 
shower baths should be employed. 

The following prescription is useful in the treatment of hysteria, 
particularly when associated with marked despondency: The hoLair 
bath is applied for five minutes; then the circular douche, under twenty- 
five pounds pressure, at 85° F., and reduced gradually to 60° F., is ad¬ 
ministered for thirty seconds. The spray douche at 65° F. is then given 
for five seconds, and finally the jet douche at 50° F. is applied for three 
seconds over the back. This treatment may need to be prolonged for 
months. 

Infantile Paralysis .—There exists at present neither a method to cure 
nor a means to arrest this dread scourge. Treatment, however, may 
mitigate the symptoms and by thus easing the patient may conserve his 
strength and enhance his resistance. Lumbar puncture relieves the pres¬ 
sure on the inflamed edematous nerve cells and may withdraw some of the 
noxious agent; the toxins circulating in the blood and lymph may be 
diluted by saline infusions or by blood transfusions; both of these meas¬ 
ures will be reenforced by warm baths. 

Repeated warm baths were formerly used to induce, through sweating, 
the elimination of the toxins of infantile paralysis. The periodic immer¬ 
sion and removal of the excessively tender victim entailed much suffering. 
Oppenheim and Wickman advised against this means of inducing dia¬ 
phoresis and recommended the employment of packs instead. But even 
the manipulations necessary to apply packs are often intolerable. Meddle¬ 
some therapy in poliomyelitis may be disastrous. The patient must not 
be handled. The most enlightened care is that which ensures to the child 


SPECIAL HYDROTHERAPY 


447 


the least possible disturbance. There is no means of sheltering the child 
more efficacious than the continuous warm bath properly given. The bath 
should be a hammock bath and all necessary adjustments for the comfort¬ 
able suspension of the patient in it should be made before he is moved. 
With all gentleness, and with as little noise and disturbance as possible, 
the patient should be lifted up by means of his bed sheet without touching 
him, should be carefully lowered into his bath and the bed sheet should 
be left under him. None other than those needed should be present. 
The bath should contain just enough water to cover him to the 
neck. 

The toxic action and the pressure of the serous and of the cellular 
exudate first irritate the invaded nerve tissues. Most of the acute symp¬ 
toms result from the irritation of the motor nerve cells in the anterior 
horn of the spinal cord. If the irritation continues the nerve cells die and 
permanent atrophy of the muscle occurs; but the first effect is to increase 
the tonicity of the muscles innervated from the implicated nerve cells so 
that involuntary and painful twitching and spasms occur, with exceed¬ 
ing tenderness. The muscular spasm is not only maintained and ag¬ 
gravated, it may even be caused by external stimuli. The hot bath reduces 
muscular spasm and provides an unchanging, sheltered, sedative environ¬ 
ment in which external stimuli are minimized. Once in the hot bath the 
patient need not be moved, and his exquisitely sensitive nerves are spared 
the heaviness of bed clothes, and much of the weight of his body. His 
terror of approach, his agony on movement, quickly diminish, and as his 
muscles relax the troublesome retention of urine spontaneously disappears. 
So far as sleep, peace, and relief from pain can strengthen his vitality, 
the warm bath aids him and this aid may suffice to determine a non-fatal 
issue. 

Insomnia.—Sleeplessness is frequently associated with cerebral hyper¬ 
emia, but even if it depends upon other factors the wet pack for one to 
one and one-half hours is an admirable measure. Nightly sitz baths at 
80° F., lowered two degrees every day, until 50° F. is reached, applied 
for three minutes, are of value. The warm bath at 90° to 98° F. applied 
for thirty minutes before retiring may produce sleep if the patient, after 
being rapidly dried, be hurried into a warm bed. The room must be warm 
and there must be no delay between emergence from the bath and entrance 
into bed. When insomnia is due to a relative ischemia of the feet the 
best treatment is a running cold foot bath for a few minutes, followed by 
drying with a rough towel (Broadbent). A cold wet towel applied around 
the neck while a patient is in bed may yield sleep. Sea-bathing often 
has a soporific effect. 

Acute Myelitis.—The application of the cold coil to the spine for a 
long period of time gives the best results. The temperature should be 
kept at 54° F. When the acute process has dwindled, half baths and the 


448 


HYDROTHERAPY AND BALNEOLOGY 


hammock or continuous bath may be employed. Heat should never be 
used in the early stages of the disease. 

Chronic Myelitis. —The hammock bath at 95° to 100° F., and the con¬ 
tinuous bath under the same thermic conditions, may exert a beneficial 
effect. The half bath at a temperature of 82° to 86° E. given from four 
to eight minutes with moderate friction and gently applied affusions 
should be tried. 

Neuralgia. —Warm baths are of benefit to the neuralgias of the head. 
The hot fomentation may be tried. In sciatica the Scotch douche achieves 
wonderful results. The steam cabinet or the hot bath pack followed by 
the cool half bath may be substituted for the Scotch douche. The latter 
exerts its greatest effects in recently developed cases. Indeed, one treat¬ 
ment may cure. The effect of the jet and the Scotch douche, follow¬ 
ing a warm application, is decidedly happy. A hot-air bath at 175° F. 
for eight minutes, followed by a jet douche applied to the spine and 
the affected part for thirty to sixty seconds, beginning at 90° F. and 
decreasing to 60° E., may be employed. Then under twenty-pound pres¬ 
sure the Scotch douche at 60° and 105° F. is directed against the ver¬ 
tebral column. Ice-bags to the sciatic nerve have been endorsed. The 
antineuralgic value of hydriatric measures is demonstrated by the record 
of Winternitz’s clinic. He treated five hundred and eighty-five cases of 
all types of neuralgias, and all but twenty-nine were cured or improved. 

Neurasthenia. —A “neurovascular training” as devised by Baruch is 
an absolute necessity to the majority of neurasthenics. Great care must 
be practiced both in the reduction of temperature and in the change of 
measures. To commence, an ablution of 85° E. may be given every 
morning and daily the temperature be lowered until an ablution of the 
trunk with very cold water is succeeded promptly by a good reaction. 
Then the ablutions are supplanted by affusions, which are graduated in 
the same fashion. Later the drip sheets supersede the affusion. The 
fan douche at 80° E. is then applied for one minute to the trunk and 
the extremities and is followed by the jet douche at 70° E. on the back 
for thirty seconds. The temperature of both douches is decreased one to 
two degrees daily until the lowest tolerable degree of cold is reached, 
while the pressure is slowly increased to twenty pounds. Half baths at 
78° to 86° F., coupled with affusion and rubbing until a good reaction 
results, are of value. Later, cold applications may follow. To avoid 
heat loss the treatment should be given upon arising or after the hot wet 
pack or hot-air bath. The salt rub with subsequent fan douche at 92° to 
99° F. applied from four to eight minutes along the spine, thorax, and 
extremities possesses great value. 

Neuritis. —The hot applications usually afford great relief. The hot- 
bath pack, hot compresses, and hot baths of 104° F. may be used. The 
steam douche will be found of value. Should the neuritis be occa- 


SPECIAL HYDROTHERAPY 


449 


sioned by trauma an ice-pack or a poultice should be employed locally. 
Magnesium sulphate compresses at 50° F. may be used for the neuritis 
due to alcoholism. Wet packs applied one hour daily hasten recovery 
after tenderness subsides. An affusion at 50° to 60° F. should follow 
the pack. 

Occupation Neuroses.— Shower baths at 45° to 60° F., combined with 
a fan douche at the same temperature, applied locally, yield excellent 
results. The cold coil, ice-poultice, and the ice-bag as continuous meas¬ 
ures are valuable auxiliaries. The ice-bag and ice-poultice should be 
withdrawn fifteen minutes in each hour. Low temperature applications 
are aided by strong mechanical stimulation. Passive motion is highly 
effective. 

Paralysis. —Toxemias and intoxications are responsible for many of 
the limited palsies; in these cases the general emunctories should be stim¬ 
ulated. Circulation to the paralyzed parts should be increased. The 
steam bath or the hot-air bath for eight to fifteen minutes, succeeded by 
a cold ablution at 45° to 55° F., or a cold rub, produces excellent re¬ 
sults. The Scotch douche and the wet pack at 65° F. for two hours are 
useful measures. The palsies which follow diphtheria are benefited by 
the daily use of half baths at 70° to 75° F. for two to five minutes. Vig¬ 
orous affusions should accompany these baths. 

Tabes Dorsalis. —Happy results are often produced by alternating 
temperature applications followed by gentle rubbing. The thermic range 
of these applications should be very slight. Baths at 95° to 100° F. for 
thirty minutes to one hour may be employed. For the arterial spasms, 
irrespective of the site, alternating temperature sitz baths and the cold 
coil placed to the spine may be tried. As a rule, however, the crises are 
little affected by treatment. The following prescription from Hinsdale 
is effective in the beginning of the disease: The hot-air baths for eight 
to ten minutes, the circular douche under twenty pounds pressure for 
two minutes at 90° to 105° F., followed by the jet douche at fifteen 
pounds at 85° to 100° F. for one minute. Then for one-half minute at 
85° to 105° F. under fifteen pounds pressure the Scotch douche is applied; 
and the fan douche at 80° to 85° F. under fifteen to twenty pounds pres¬ 
sure for twenty seconds, followed by an alcohol rub, concludes the treat¬ 
ment. Daily the temperature should be decreased and the pressure in¬ 
creased until the fan douche reaches 70° F. and Scotch and jet douches 
are driven by a force of twenty pounds. Half baths at 80° to 85° F. 
applied from five to ten minutes may be used in the late ataxic stage. If 
the ataxia is marked or paralysis is present circular douches at 100° to 
105° F. under twenty pounds pressure, applied for one minute, following 
the application of the hot-air bath for ten minutes, are of value. The 
fan douche at 105° F. to 120° F. will increase the effect of the 
above. Moderate sea-bathing may be of valuej but this should be 


450 HYDROTHERAPY AND BALNEOLOGY 

employed very cautiously. The hammock bath at 100° to 105° F. is of 
benefit. 

Spasmodic Tic.—Cold shower baths at 40° to 55° E. for one to two 
minutes produce the best results in this disorder. In general, stimulat¬ 
ing measures are applied, but the treatment is unsatisfactory. 

Mania.—In cases of cerebral excitement which accompanies alcohol¬ 
ism, dementia prsecox, chorea, epilepsy, paresis, puerperal states, and 
general acute manias, the hammock bath produces excellent results. The 
temperature of the bath should be between 95° to 100° F. and should 
never fall below 95° F. Covering the top of the bathtub with a blanket 
or other covering prevents heat radiation and tends to keep the tem¬ 
perature of the water constant. When the bath is continued for several 
hours reduction of the excitement is produced. The duration of the bath, 
if the patient gives no contra-indications, is proportionate to the amount 
of excitement present. When the bath is ended the patient should be 
quickly covered by a warm blanket and rapidly placed in a warmed bed. 
Daily douches graduated from 100° to 75° F. decrease the cerebral 
exaltation. The continuous bath applied daily from ten to twelve hours 
at a temperature from 95° to 105° F. gives even superior results to those 
obtained by the use of the hammock bath. Profuse diaphoresis induced by 
means of hot air, electric light, or steam cabinets succeeded by a rain 
bath of five minutes at a temperature of 95° F., decreased to 85° F., is 
of value. 


Diseases of the Joints 

Rheumatoid Arthritis.—Hydrotherapeutic efforts are directed toward 
the mitigation of pain, the promotion of mobility, and the improvement 
of circulation. Five-minute applications of the hot-air bath (165° F. to 
175° F.) followed by rapid ablutions of water of an initial temperature 
of 95° F., and reduced one degree each day until 60° F. is reached, 
often yield valuable results. The circular douche at a temperature above 
85° F. is a useful auxiliary measure. Additional means are the circular 
compresses and the Scotch douche. 

Arthritis Deformans.—Hot-water baths are contra-indicated except in 
the earliest stage of the disease. Hot-air baths, hot-sand baths, and electric- 
light baths exert most potent effect in checking its progress. It is pos¬ 
sible by these means to reduce the amount of inflammatory fluid in and 
around the joints, and to increase the range of movement of the articula¬ 
tion, if extensive hyperplasia of the joints be not present. The circular 
jet and Scotch douche applied for a length of time, depending upon the 
individual case, should follow these applications of heat. 

Gonorrheal Arthritis.—In the acute stage the moist heat of hot baths 
and hot douches at a temperature of 100° to 105° F. is indicated. 


SPECIAL HYDKOTHERAPY 


451 


Hot dry packs for one hour should follow these measures. Local appli¬ 
cations of hot compresses will often ameliorate the pain in very severe 
cases, during which there should be no massage of the affected parts. In 
chronic gonorrheal arthritis douches are extremely potent measures. They 
are best applied after a hot-air cabinet bath of from five to fifteen min¬ 
utes’ duration. The jet douche at twenty pounds pressure is usually em¬ 
ployed as a test measure, and if it is well tolerated it is continued with 
gradually increased pressure up to thirty pounds. In the more chronic 
cases full pressure cold douche and moderate manipulations are the meas¬ 
ures of choice. A careful watch must he kept for the usual cardiac 
accompaniments of an acute arthritis. 

Acute Articular Rheumatism.—In those who possess the so-called 
rheumatic tendencies prophylactic hydrotherapeutic measures may avert 
the development of the disease. Moderately cold salt water baths at 85° 
to 90° E., with subsequent marked rubbing for ten to fifteen minutes, 
often rectify the rheumatic predisposition. In the treatment of the ac¬ 
tual disease, if the pulse exceeds 90 and great tenderness be present, 
baths in the tub are contra-indicated. With a pulse at 80, tub baths 
of an initial temperature of 98° F. may be used. If endocarditis or peri¬ 
carditis be present, the bath temperature should not exceed 98° F. at any 
time. The cold precordial coil applied thirty minutes to one hour, two or 
three times a day, strengthens the heart and may prevent the occurrence 
of cardiac complications. The temperature may be reduced and elimina¬ 
tion increased by the repeated use of the wet pack. Two or three are 
given, and the last is maintained in place until diaphoresis occurs. Then 
a bath at 95° to 100° E. of five minutes’ duration is given. In absence 
of much pain the pyrexia may be lowered further by a cold rub after 
the concluding wet pack is removed. An increase in fever and pain 
warrants a repetition of the complete procedure. Milder cases may be 
treated by sponge baths at 104° to 110° F., three minutes, with suceed- 
ing friction in cold water at 60° and 70° F. If hyperpyrexia (105° to 
106° F.) be present, the following routine will yield excellent results: 
The patient is placed in a bath at a temperature of 85° to 95° F., 
which is then slowly reduced to 60° F. The duration of the bath is 
from fifteen to thirty minutes, being concluded when the fever drops 
to 101° F. If the temperature descends even to 98.5° F., after 
withdrawal from the bath, in the absence of other signs, no alarm need 
be felt. 

Local magnesium sulphate compresses at 140° to 160° F. if changed 
constantly may exert a marked amelioration after the procedure has been 
in force twenty minutes. Water at 70° F. is applied with rubbing, after 
which rest in bed is required for at least an hour. Even during con¬ 
valescence a cold rub should be given upon awakening in order to lessen 
the danger of relapse. 


452 


HYDROTHERAPY AND BALNEOLOGY 


Intoxications and Toxemias 

Alcoholism— Acute .—The relief of this condition obtained by the 
use of the Turkish bath is a matter of lay knowledge. A prolonged warm 
bath at 100° to 102° E., with subsequent inactivity, preferably in bed, 
may be substituted for the Turkish bath. 

Chronic. —Saline infusion may be given for nervous manifestations, 
such as excitement, insomnia, and neuritis. They often yield to prolonged 
wet packs. Many cases respond best to hot tub baths, lasting five to twenty 
minutes, at 102° to 104° F., with subsequent hot packs for ten to twenty 
minutes. In absence of vascular disease cold sponging may be employed. 

Chronic Arsenic Poisoning.—Elimination of the offending agent is 
the hydrotherapeutic aim. Steam cabinet baths lasting ten to fifteen 
minutes, and the hot-air cabinet, for the same length of time, followed 
by Scotch and jet douches or a cold rain bath, are efficient in this respect. 
Wet packs often exert an analgesic effect upon the intense pain sometimes 
present in arsenical intoxication. 

Chronic Mercurialism.—The use of the hot tub bath at 104° F. for 
ten to thirty minutes with the succeeding use of hot dry blanket packs 
for twenty minutes is advocated. An alcohol rub is usually given when 
the pack is discontinued. 

Chronic Morphinism.—The treatment of this habit is similar to that 
outlined for chronic alcoholism. General invigorating procedures are 
valuable. 

Chronic Plumbism.—Elimination by all channels should be increased. 
The means at our disposal to accomplish this is the steam cabinet for fif¬ 
teen to twenty minutes or the hot-air cabinet bath. Douches, as the 
circular or fan, should follow these diaphoretic measures. Colic may be 
relieved and elimination from the intestine aided, by enteroclysis. Three 
to five liters of warm water may be used, and, if expulsion ensues, may 
be repeated in one-half hour. The hot abdominal coil has also proved 
of service in controlling colic. Paralytic conditions are treated by Scotch 
douches and cold fan douches. 

Chronic Nicotinism.—Here the treatment may be conducted as in 
chronic alcoholism. 

Thermic Fever.—Treatment should be instituted without delay. Cold 
measures, combined with friction, are indicated, but some relief can be 
accomplished by simply hurling cold water against the body. Ice-cold 
sprays and affusions, cold sheet rubs with vigorous friction, ice-cold ene- 
mata, and ice-rubs are the measures usually adopted. The ice-pack is per¬ 
nicious. Irrespective of the form of treatment used, the patient should be 
completely disrobed and frequently renewed ice-pads should be placed to 
the neck and an ice-cap adjusted to the head. 


BALNEOLOGY 


453 


When the temperature is high, 106° to 110° F., a cold sheet hath ac¬ 
companied by strong nibbing should be continued until the temperature 
reaches 102° to 103° F. During the bath the patient should have cold 
water thrown over him, and after the bath should be placed in bed with the 
ice-cap in position. Enemata gradually reduced from 90° to 45° F. should 
be given in amounts from four to five pints. These may be given until 
the axillary temperature falls to 102° E. 

The O’Dwyer treatment with affusions had the best results in the New 
York epidemic in 1896. The mortality with this form of management 
was only 6 per cent, while with all other forms it ranged from 11 to 
33 per cent. This treatment is as follows: After the patient has been 
covered by a sheet and placed on a stretcher, an attendant standing a few 
feet away from the patient hurls cold water from a dipper on him until 
the temperature taken per rectum is 103° F. As the body cools vigorous 
friction is given. 

The cold sponge bath is of value. The flower-pot ice water spray may 
be used. 


BALNEOLOGY 

Introduction.—Balneology is concerned with the treatment of disease 
by mineral waters. A mineral water is water from a natural source, 
which contains mineral substances in solution. Since no natural water 
is absolutely free from minerals, all waters found in nature may be classed 
as mineral waters. There is, therefore, no sharp distinction between 
balneology and hydrotherapy. Hydrotherapy deals mainly with the ex¬ 
ternal application of common water; balneology with the external and in¬ 
ternal application of waters from special sources. 

The therapeutic actions inherent in special waters not by virtue of 
the aqueous nature alone, but by virtue of the potency of the dissolved 
constituents, are utilized in balneology. At some springs only drinking 
is employed; at others mainly bathing; but at most both bathing and 
drinking are practiced. Yichy waters have specific curative properties 
in diabetes and glycosuria; earthy waters, in gravel and stone; Kreuz- 
nach is especially efficacious in uterine complaints; Aix-la-Chapelle, in 
syphilis. Chemists have elaborately analyzed these waters to detect the 
elusive property in which the remedial power resides. Weary columns 
of statistics reveal even the most minute traces of organic or inorganic, 
solid or gaseous matter which the water contains, but cast no light upon 
the mode of action of the waters. Springs which contain the most diverse 
mineral substances in the proportions which are most dissimilar enjoy 
apparently an equal potency in the treatment of the same disease. Dif¬ 
ferent persons with the same disease may not be curable at the same 


454 


HYDROTHERAPY AND BALNEOLOGY 


spring. Artificially prepared waters of apparently identical composition 
are admittedly less efficacious, and even questionably useful. 

To wliat, then, does the natural source owe its value ? Recently radio¬ 
activity has been demonstrated in the waters of many springs. Doubt¬ 
less such radio-activity is powerful to benefit; hut the patient must first 
he thoroughly educated to its significance and then he convinced of its 
presence. To the less credulous the waters have properties more tan¬ 
gible and commonplace. If analysis shows a special source to be well 
aerated and to contain sodium, calcium, or other base combined with 
hydrochloric, sulphuric, or other acid, the merit of the water is that 
inherent in water the world over, plus that due to its gaseous, metallic, 
or metalloid constituents. The value of such constituents is their es¬ 
sential value. It is no mysterious virtue. Iron or arsenic exerts the 
same pharmacological effect whether it be administered as a natural 
solution or as a pharmaceutical preparation. The action of alkaline or 
of sulphurated waters does not vary when it is sought in an Arcadian 
spa and when it is invoked in a crowded town. The worth of balneo¬ 
logical treatment lies not in the water and its contents. These have a 
certain importance, hut the prime factors in the cure are the psychic 
influences which accompany it; the absence of work and worry; the 
change of climate and environment which invest it with healthy inter¬ 
est ; the regulation of sleep and diet and exercise which reenforce it; and 
the medical skill which controls all. 

In spas, to every mental stimulus of a non-religious nature which 
tends to health, appeal is made. The physician who recommends the 
treatment begins the therapeutic suggestion by his declaration of faith 
in the spa and his panegyric on the evidences of its curative powers. A 
belief in the efficacy of the spa is accepted by natives as part of their 
national inheritance, one of the virtues of their fatherland; by foreign¬ 
ers, as conferring upon them at once a certain desirable cosmopolitanism. 
The pinnacle of faith is reached by the spa doctor who sees in the waters 
cure for everything, from fibroid tumors to supernumerary digits. At 
the spa itself everybody assembles for one purpose—to strive for health. 
The social instinct among the similarly sick, the atmosphere of salutary 
competition among convalescents, the regular restful hygienic mode of 
life pursued, and the climatic conditions enjoyed, exercise a cumulative 
curative action on the overstrained, the depressed, and the weary. Die¬ 
tetic and hygienic regulations are more or less stringently enforced. The 
regime in itself is curative for the majority of the slightly ailing who 
flock to these resorts. The routine flushing of the system with innocuous 
fluids eliminates the lingering toxins of years. In nearly all spas the 
medical skill at the disposal of the visitors is excellent—skill in handling 
the particular maladies which are specially catered for at the spa; and, 
particularly, skill in alleviating slight conditions superimposed upon the 


BALNEOLOGY 


455 


main disease, conditions which can he remedied by attention to therapeu¬ 
tic detail. The health resort physician takes cognizance of every mental 
and physical aspect of his patients. His psychotherapeutic skill is, as a 
rule, far superior to that of his colleague in general practice. Aided by 
the atmosphere which pervades such places, an atmosphere similar to 
that which Bernheim helped to create at Nancy, and supported by mu¬ 
nicipal and institutional authority, the doctor of the spa is in the posi¬ 
tion of a health-giver whose word is law. His rule is salutary. His 
prescriptions are edicts of health which all must obey. No private physi¬ 
cian could impose such a regime, could practice such beneficent tyranny, 
as is welcomed at spas. Spas are little more than institutions where 
hygiene, hydrotherapy, and faith healing are practiced, and often the 
greatest of these is faith healing. 

Composition of Mineral Waters.—The mineral waters contain either 
saline or gaseous constituents, or both. They are used internally and 
externally. Externally they are used as baths partly on account of the 
stimulating action of their contained salts and gases, and partly on ac¬ 
count of the elevated temperature which they often have. 

The mineral constituents of spa waters are derived from the perco¬ 
lation of rain water through the soil and through various strata of the 
earth’s surface. On analysis of them, sodium, potassium, magnesium, 
calcium, iron, manganese, lithium, and arsenic are the usual bases en¬ 
countered; they are combined with hydrochloric, sulphuric, carbonic, 
hydrohromic, and hydriodic acids. Silica is often present. Sometimes 
the metals occur as sulphids. Oxygen, carbon dioxid, nitrogen, sulphur¬ 
ated hydrogen, and other gases may be present in solution. 

The amount of gas which will dissolve in a liter of water varies with 
the nature of the gas. Fresh water dissolves more gas than salt water, but 
the most important factor in the solution of a gas is the pressure of the 
gas. The most valuable of the gases in balneology is carbonic acid. At 
0° C. and 760 mm. pressure, 1 liter of pure water can absorb 1,713 
liters of C0 2 ; and the solution is saturated. At greater pressure more 
C0 2 can he dissolved; the solution can be supersaturated. The dissolved 
gas is invisible and its solution is not sparkling. Heat or agitation or 
reduction of pressure converts the tranquil solution of carbonic acid gas 
into a sparkling, bubbling liquid owing to the throwing out of solution of 
the carbonic acid gas. In comparing the C0 2 contents of various springs 
it is, for practical purposes, only necessary to ascertain the degree of 
supersaturation. Anthony, by experiment, determined that the super¬ 
saturation was 25 per cent at Bad Nauheim; 31 per cent at High Bock 
Baths, Saratoga; 33 per cent at Kayaderosseras Baths, Saratoga; 38 per 
cent at Bad Momburg; 45 per cent at Bad Kissingen; 50 per cent at 
Bruckenau and 55 per cent at Lincoln Baths, Saratoga. At the Lincoln 
Baths, Saratoga, the greatest supersaturation known in balneology is to 


456 


HYDROTHERAPY AND BALNEOLOGY 


be found. The efficiency of the Nauheim Bath is largely due to the action 
of carbonic acid gas bubbles on the skin. This action can be obtained in 
unequaled degree at Saratoga Springs, New York. 

Temperature.—The temperature of the waters varies greatly. Waters 
which issue hot, derive their heat from that which exists at great depths 
in the earth. Indeed, it has been alleged that the hotter the spring the 
deeper is its source. Springs that have a temperature above the average 
of the locality in which they occur are called thermal. Thermal springs 
of a temperature between 70° E. and 98° F. are distinguished as warm; 
and those above 98° E. as hot. The temperature of the waters at Aix-la- 
Chapelle is 167° F.; at Carlsbad, 162° E.; at Bath, 120° F. The follow¬ 
ing list (Hinsdale) gives the location and distribution of the chief thermal 


springs in the United States : 

Temperature 
Degrees F. 

Lebanon Spring, Columbia Co., New York. ... 75 

Spring near Carlisle, Perry Co., Pennsylvania. 72 

Rockbridge Baths, Virginia. 74 

Sweet Chalybeate, Alleghany Co., Virginia. 75 

McHenry’s Thermal Spring, Scott Co., Virginia. 68 

Healing Springs, Bath Co., Virginia. 84 

Warm Springs, Bath Co., Virginia. 96.3 

Hot Springs, Bath Co., Virginia. 106 

Berkeley Springs, Morgan Co., Virginia. 74 

Sweet Springs, Monroe Co., West Virginia. 79 

New River White Sulphur, Giles Co., West Virginia. 85 

Hot Springs, Buncombe Co., North Carolina.. 92-117 

Citadel Green, Charleston, South Carolina. 99.5 

Warm Springs, Meriwether Co., Georgia. 70- 90 

Livingston Spring, Sumter Co., Alabama. 68 

Bailey’s Springs, Alabama. 72- 80 

Hot Springs, Arkansas. 46-147 

Hot Springs, South Dakota. 98 

Liberty Hot Springs, Colorado. 140-150 

Hot Springs, Canyon City, Colorado. 162 

Hot Sulphur Springs, Middle Park, Colorado. 110-117 

Glenwood Springs, Colorado. 124 

Idaho Springs, Colorado. 106 

Las Vegas Springs, New Mexico. 110-140 

Hudson Hot Springs, New Mexico. 142 

Ojo Caliente, Taos Co., New Mexico. 90-122 


At thermal baths local painful conditions, nerve or joint troubles of 
gouty or rheumatic origin, are treated. 

Radio-activity .-^The radio-activity of mineral waters arises from the 
presence of a gas known as the radium emanation. This gas is derived 
from the radio-active salts contained in the earth where the spring has its 
source. The emanation is soluble in water, but decomposes continuously 
at a known rate, and, like other gases, is driven out of solution by boiling. 




























BALNEOLOGY 


457 


Radio-activity is estimated by means of the electroscope or, with greater 
accuracy, of the fontactoscope of Engler and Sieveking. The result is 
stated in Mache units (M. U.) but confusion in standardizing the units 
exists, so the radio-active values of various springs are not easily 
judged. Shearer in his report upon the radio-activity of Glen Springs 
states that the Nauheim Spring there contains 68 M. U. per liter and 
cites from Radium (April, 1915) the radio-activity of Hot Springs, 
Arkansas, as varying between 0.7 and 23.6 M. U.; of Saratoga Springs, 
1.08 and 1.04 M. U.; and of Colorado Springs, 0.21 and 10.4 M. U. 
Semblin, quoted by Hinsdale, estimates that there are 274 M. XL per 
liter in Magnesia Spring, 214 M. U. in Boiler Spring, 157 M. U. in Hot 
Sulphur Spring, and 109 M. U. in Swimming Pool Spring at Hot 
Springs, Virginia. Radio-active mineral waters are used chiefly to ac¬ 
celerate metabolism. Success is said closely to attend them in the treat¬ 
ment of the metabolic toxemias, which cause gouty and rheumatoid states 
with accompaniments as myositis, neuritis, and arteriosclerosis. 

Classification 

The amounts of the various constituents vary greatly in different 
sources. According to the essential constituents of the water, sources 
are classified as indifferent, alkaline, saline, chalybeate, sulphurous, etc. 
Many waters do not belong to any one group. Thus, saline sulphur 
springs are common; others could rightfully be classed in any of several 
categories. Hence, this mode of classification does not distinctly differ¬ 
entiate, but merely groups somewhat similar waters conveniently together. 
The following are some of the most important sources: 

Simple Thermal Waters.—Simple Thermal Waters include waters of 
high temperature and small mineral content. 

America. —See list enumerated under Temperature (page 456). 

Great Britain. —Bath ; Buxton; Matlock. 

France. —Bagneres de Bigorre; Neris; Bagnoles de POrne; Plom- 
bieres; Dax; St. Amand. 

Germany and Austria. —Badenweiler; Teplitz, Bohemia; Gastein, 
Salzburg, Austria; Wildbad, Wurt-temberg; Schlangenbad (near Wies¬ 
baden). 

Italy. —Battaglia; Bormio; Pozzuoli. 

Switzerland. —Loeche-les-Bains; Ragatz. 

These waters are usually “soft”; they are not frequently used inter¬ 
nally, but are employed almost solely as baths. 

Common Salt Waters.—As common salt is of almost invariable oc¬ 
currence in natural waters, this class has indefinite and arbitrary limits. 
In the waters which are here mentioned common salt is the essential 
constituent. 


458 


HYDRO THERAPY AND BALNEOLOGY 


America. —Fruit Port, Michigan; Grand Haven, Michigan; Mount 
Clemens Mineral Springs; Spring Lake Well; Salt Spring, Virginia; 
Ocean Spring, Alabama. 

Great Britain. —Droitwich (brine, 300 parts per 1,000), Worcester¬ 
shire; Nantwich (brine) ; Woodhall Spa (chloro-bromo-iodid), Lincoln¬ 
shire. 

France. —Bourbonne-les-Bains (hot) ; Salies de Bearn; Chatelguyon 
(warm, gaseous); Salins du Jura; La Mouilliere (chloro-bromo-iodid); 
Salins Moutiers (warm). 

Germany and Austria. —Baden Baden (weak, 2 parts per 1,000) ; 
Nauheim (warm, gaseous) ; Hesse (near Frankfort-on-Main) ; Berchtes- 
gaden, upper Bavaria; Oeynhausen, Westphalia; Homburg (cold; con¬ 
tain also bicarbonate of iron) (near Frankfort-on-Main) ; Ischl, Salz- 
kammergut, Austria; Reichenhall, Bavaria; Kissingen, Bavaria; Soden 
(near Frankfort-on-Main) ; Kreuznach, Rhine Province; Wiesbaden 
(hot). 

Switzerland. —Bex; Wildegg. 

Alkaline Waters.—Waters containing sodium bicarbonate. Three 
subgroups: (1) simple alkaline waters; (2) alkaline and common salt 
waters; (3) alkaline and sodium sulphate waters. 

America. —Capon Springs, Virginia; Glen wood Springs, Colorado; 
Glen Summit Springs, Pennsylvania; Geyser Spa, California; Gettys¬ 
burg Springs, Pennsylvania; Manitou Soda Spring, Colorado; Minnequa 
Springs, Pennsylvania; Saratoga Springs, New York. 

France. —Vais, 1; 3 Vichy, 1; Allier; Royat, 2. 

Germany and Austria.- —Bilin, 1; Fachingen, 1; Carlsbad, 3, Bo¬ 
hemia; Neuenahr, 1, Coblentz; Franzensbad, 3, Bohemia; Ems, 2, Hesse- 
Nassau; Marienbad, 3, Bohemia. 

Switzerland. —Tarasp, 3. 

Bitter Waters.—These contain chiefly magnesium sulphate. 

Great Britain. —Cheltenham (chlorids also) ; Leamington (chlorids 
also). 

France. —Brides. 

Germany and Austria. —Apenta; Friedrichshall; Pullna. 

Spain. —Rubinat. 

Chalybeate or Iron Waters.—These waters contain iron in medicinal 
quantities. 

America. —Rawley Springs; Rock Iron Springs; Church Hill Alum 
Springs, and others, Virginia; Sharon Springs, Saratoga Springs, New 
York; Pacific Congress Springs, California. 

England. —Tunbridge Wells. 

France. —Forges-les-Eaux; Orezza. 

Belgium. —Spa. 


3 The figures refer to the subgroup. 



BALNEOLOGY 


459 


Germany and Austria .—Booklet; Pyrmont, Waldeck; Bruckenau; 
Rippoldsau; Elster, Saxony; Schwalbach; Petersthal. 

Italy. —Santa Catarina. 

Switzerland. —St. Moritz. 

Calcareous Group.—These waters contain salts of alkaline earths, cal¬ 
cium and magnesium sulphate, and carbonate. 

America. —Cherry Valley, New York; Holston, Virginia; Chitte- 
nango, New York; Waukesha, Wisconsin; Clifton Springs, New York; 
Tate Epsom, Tennessee; Bedford, Pennsylvania; Alum Bock, California; 
Catoosa, Georgia, etc. 

England. —Bath. 

France. —Bagneres de Bigorre; Contrexeville; Vittel. 

Germany and Austria. —Inselbad; Lippspring; Wildingen. 

Switzerland. —Loeche-les-Bains; Weissenberg. 

Sulphur Waters.—These waters contain sulphids. Many of them also 
contain chlorids. Some of them are warm. 

America. —Calistoga Springs, California; Santa Barbara Springs, 
California; Glenwood Springs, Colorado; Hot Sulphur Springs, Colo¬ 
rado ; also in Utah and Arkansas. 

British Isles. —Ballynahinch (Co. Down, Ireland) ; Harrogate, Eng¬ 
land (13 per 1,000 NaCl) ; Llandrindod Wells, Wales; Moffat, Scotland; 
Strathpeffer, Scotland. 

France. —Aix-les-Bains (warm); Louchon; Allevard; Pierrefonds; 
Amelie-les-Bains (hot); St. Honore-les-Bains; Barege; St. Sauveur; 
Canterets (warm) ; Uriage; Eaux Bonnes (warm). 

Germany and Austria.— Aix-la-Chapelle; Baden; Weilbach, Nassau. 

Switzerland. —Baden; Heustrich; Schinznach; Gurnigel; Lenk. 

Egypt. —-Helouan. 

Arsenical Waters.—These waters contain arsenites or arsenates. 

America. —Crockett Arsenic Lithia Springs (Virginia) ; Thompson’s 
Bromine Arsenic, North Carolina; Harbin Hot Sulphur Springs, Cali¬ 
fornia. 

France. —La Bourboule; Boussang; Vais. 

Germany and Austria. —Cudowa; Roncegno; Linda Pausa; Levico, 
South Tyrol. 

Italy. —Civilina; Ceresole Beale. 

The Action of Mineral Waters 

The effect of the ingestion of the large quantities of water which 
forms part, of the routine treatment at mineral springs is to flush out the 
stomach, intestine, kidneys, and other organs. The water, by its bulk, 
stimulates peristalsis, and voids, in solution or suspension, the putrescent 
material from the bowels. Some of the water is absorbed. The bulk of 


460 


HYDROTHERAPY AND BALNEOLOGY 


the circulating fluid is increased; the greater volume affords endocardial 
stimulation and the circulatory efficiency may be enhanced. The resulting 
increased blood-pressure promotes diuresis. The vital processes are all 
quickened; tissue change increases; mucous membranes secrete more 
freely; and the skin glands function more actively. To dilute toxins; to 
dissolve them; and to promote their excretion, are the main actions of 
water. 

But a feeble atonic stomach musculature may not lightly tolerate the 
ingestion of large volumes of water; embarrassed hearts may perceptibly 
fail under the added burden which must be propelled; and overworked 
diseased kidneys may quickly be exhausted by the laborious functional 
activity thus demanded. 

Action of Salines. —The dialytic and irritant properties of salines 
inhibit absorption of liquids, augment peristalsis, and increase the fluid 
contents of the intestines, so as to produce more or less free purgation. 
The presence of increase of salts in the blood causes a livelier interchange 
between the circulating blood and the fluid in the tissue spaces; diuresis 
ensues; a mild expectorant action is produced; and metabolism generally 
is increased. 

Salines are said to increase the solubility and diffusibility of albumins. 
In food a considerable amount of salt is customarily ingested. How far 
the added quantities of salines, which are absorbed during mineral water 
cures, exert an influence on metabolism, is doubtful. The action of the 
salines varies somewhat according as the base and the acid radical which 
they contain. The action of the metallic element need not further be dis¬ 
cussed here. The rate of diffusion of chlorids, sulphates, and iodids 
determines whether they are essentially purgative or diuretic. Radicals 
of large molecular weight, such as sulphates, diffuse with difficulty and, 
therefore, tend to act mainly as cathartics. Whereas, with radicals of 
small molecular weight, such as chlorids, an interchange takes place 
readily between the bowel contents and the portal circulation, so that a 
considerable proportion of the salt may be ingested. Further details as 
regards the mechanism of the action of salines belong more properly to 
the realm of pharmacology. Salt and bitter springs are used in constipa¬ 
tion, portal stagnation, chronic gastro-enteritis, chronic respiratory, pelvic, 
and rheumatic conditions. 

Alkalis. —The alkaline waters increase the alkalinity of the blood 
plasma, promote tissue changes, increase metabolism, and tend also to 
increase the alkalinity of the urine. As alkalinity promotes the action 
of the saliva, bile, pancreatic, and intestinal juices, alkalis enhance diges¬ 
tion. Alkalis are alleged to facilitate respiration (Voit) not only in 
the tissues, but also in the lungs, by acting as carbonic acid carriers. The 
alkaline waters are used in acid dyspepsia, constipation, gall-stones, gravel, 
gout, glycosuria, and obesity. 


BALNEOLOGY 


461 


Iron, Arsenical, Sulphide, and Earthy Waters.—Waters containing 
iron and arsenic in sufficient amounts to be of therapeutic value exert 
merely the ordinary pharmacological action of these substances. They 
are used mainly in anemias, neuralgias, and skin diseases. The action 
of the sulphide waters is not evident. They are said to stimulate secretion 
of bile and to have an expectorant action. Their use in syphilis is greatly 
lauded, but where it is most exalted, mercury is also given as a substantial 
prop to its curative powers. Sulphids in sufficient quantity are protoplas¬ 
mic poisons. To class the sulphide mineral water as an alterative is to 
admit ignorance of the basis of its action. The earthy waters, those con¬ 
taining the sulphates and carbonates of calcium chiefly, have probably 
little action apart from that of the water. They are given as antacids, 
as astringents, and sedatives, in acid dyspepsia and in diarrhea. Their 
benign flushing power is used in hepatic and gouty conditions, and in 
chronic cystitis, gravel and stone. 

Resultant Action of Mineral Waters.—Few waters have only one 
content. As the waters were classed according to their predominant con¬ 
stituent, so is their action regarded as being that mainly of this essential 
constituent; but the predominant constituent of any mineral water is not 
that which occurs in greatest quantity, but that which is most active 
medicinally. Some waters containing small quantities of arsenic exert 
more action by virtue of their arsenic than they do by virtue of all their 
other constituents. We therefore have to deal with compound actions, 
some of which are negligible, and some of which are important. Of the 
important actions some reenforce and some tend to neutralize those of the 
other constituents. The precise effect therefore of any given mineral 
water is the resultant of so many actions that it is difficult to presage, and 
we must more or less empirically base our expectations of its value upon 
observations of physicians and patients. 

In addition to these mineral factors the presence of carbonic acid gas 
also modifies the action of the waters. The carbonic acid is supposed to 
be at once stimulating and sedative. It certainly renders waters more 
pleasing to regard and more palatable to take. The physical effects of 
the impact of gas bubbles upon the skin are utilized in stimulating baths. 

Many mineral sources yield waters at high temperatures and the tem¬ 
perature also modifies the therapeutic action. 

Indications for, and Choice of, a Spa 

For those who have the habit of excess in work or in pleasure, a 
periodic visit to a spa is a useful precaution. For others “taking the 
cure” is an essential part of social routine. For others, again, especially 
the middle aged in easy circumstances, who seek relief from the tedium of 
living by intensive devotion to minor ailments, the spa is a refuge to 


462 


HYDROTHERAPY AND BALNEOLOGY 


which they retire from the monotony of family and social life, and in 
which hygienic, dietetic, and medical discipline provides them with an 
excuse and with an opportunity for cure. 

For tardy convalescence the spa is eminently desirable but not always 
necessary. In many cases, as in chlorosis, change, alone, is needed. The 
anemic country girl visits a town and quickly improves. The anemic 
town girl returns rosy from the sea, the moors, or the mountains. The 
new regime and environment are sufficient to bring about the desired 
cure. In other cases the chief factors of benefit in the change are fresh 
air and exercise; for such the locality chosen should have a slight rainfall 
in order to insure the possibility of outdoor life; the temperature is less 
important, for appropriate clothing and exercise will maintain the body 
heat. But the value of warmth in winter, to those convalescing from 
painful nervous and rheumatic conditions, and of coolness in the summer, 
to invalids from hot stuffy towns, is too well known to need emphasis. 
But when a change is imperative and medical care is still necessary the 
patient should be sent to a spa. Good sanitation, comfortable quarters, 
and constant care can there be relied upon. If a special climate be also 
desired, all climates are available to the fortunate residents of the United 
States, and there also is a choice of many different kinds of spas at the 
same latitude. 

But the main sphere of the spa is the treatment of chronic diseases. 
In the metabolic diseases the eliminating channels are cleansed and main¬ 
tained clean by the ingestion of the mineral waters and by bathing; 
dietetic discipline is enforced, so auto-intoxication ceases; physical therapy 
is practiced which, together with the radio-activity of the waters, promotes 
oxidation. The control of the bulk of the food and the regular emptying 
of the alimentary canal enables the weak and overstretched muscles of the 
stomach and bowel to renew their tone. Massage for the feeble and for 
those in pain; passive movements, regulated either by masseurs or by 
the ingenious mechanical appliances of Lander; active movements, in the 
recumbent posture for the weak; walking carefully controlled distances 
on level surfaces, or—for the stronger—up measured slopes; and finally, 
gymnastic practice, swimming, tennis, golf and other outdoor sports;— 
these means strengthen feeble cardiac and vascular muscles, tone the flabby 
voluntary muscles and promote the circulatory, digestive and mental 
processes. 

Under suitable treatment by baths, mineral waters, diet, and physical 
exercises, metabolism is thus quickened; obesity is reduced; deposits 
diminish around thickened joints and in infiltrated muscles; pain, there¬ 
fore, is alleviated, movement returns and wasted muscles recover. Dis¬ 
eased kidneys are rested and their work is lightened to their power to 
function properly. 

In cardiovascular diseases such treatment not only may arrest the 


BALNEOLOGY 


463 


morbid process, but also may so tone tbe weakened heart that edema, pain 
and breathlessness disappear; and then by carefully regulated training the 
circulatory system may be further strengthened so that even under con¬ 
siderable exertion the heart acts strongly, regularly and without em¬ 
barrassment. 

In chronic diseases of a less hopeful degree spas afford relief from the 
weariness and monotony of prolonged home treatment. New surround¬ 
ings, new physicians, new therapeutic measures seldom fail to relieve the 
depression, and they enhance the vitality of chronic invalids. 

There remain a few spas which are merely “bath houses,” but the 
modern spa is in the truest sense a health resort. Spa therapy is not con¬ 
fined to baths, diets, and exercise. Drugs and every measure which can 
combat disease are utilized, sometimes even to the exclusion of hydro¬ 
therapy. Thus, at Clifton Springs, near Bochester, New York, the spa is 
organized under the able direction of Dr. M. S. Woodbury into depart¬ 
ments of internal medicine, neurology, surgery and pathology. Hydro¬ 
therapy, balneology, electrotherapy, physical training and industrial 
therapeutics are all used there as adjuvants to rational treatment. This 
excellent institution is operated under a trust deed whieh requires that 
all receipts in excess of expenses be devoted to improving the institution 
and to the care of patients at reduced or free rates. In other spas such as 
Hot Springs, Arkansas, the American Aix-la-Chapelle, and Mount Clem¬ 
ens, Michigan, the main endeavor is to enhance the efficacy of drug treat¬ 
ment of disease. In these last two institutions unrivaled facilities for the 
treatment of syphilis exist. The administration of mercury by expert rub¬ 
bers in a careful, systematic and thorough fashion insures, as far as is 
humanly possible, freedom from the dread sequelae of this disease and 
mitigates or removes such symptoms as may arise. The absorption and 
elimination of the mercury is aided by bathing. The treatment is not 
confined to mercurial inunctions; arsphenamine and other drugs are also 
used in appropriate cases. Particularly happy results are attained in the 
nervous manifestations of syphilis in which the physical therapy relieves 
pain, promotes nutrition and strengthens the musculature while the drug 
treatment attacks the essential cause of the malady. 

All chronic diseases, except a few, such as epilepsy and tuberculosis, 
whose victims may be undesirable associates for other sufferers, are treated 
at spas. Some spas, however, because of their situation or because of the 
character of their waters are traditionally efficacious in the treatment of 
special diseases. Thus at Kreuznach, Woodhall and Kissingen, exudates 
from chronic endometritis, perimetritis and salpingitis are said to dis¬ 
appear; even fibroids have been alleged to melt before the solvent action 
of these waters. At Mannheim and at Bheine cardiac and joint sequelae 
of rheumatic fever are cured; Schlangenbad is especially lauded for the 
relief of the neuralgia which so often follows influenza and malaria; the 


464 


HYDROTHERAPY AND BALNEOLOGY 


obese and the gouty are catered for at Carlsbad and Marienbad; the 
syphilitic, at Aix-la-Chapelle; and so forth. This specialization is of 
great value. Every facility which science has devised for the treatment of 
the selected disease is provided at the spa. The spa physicians have a 
vast experience of these special ailments and great skill in their treatment, 
and the competition for health among the similarly sick at such spas is of 
considerable therapeutic value. Hence these spas often confer a more 
rapid, a greater, and a more permanent improvement than home treatment 
can attain. 

American spas are not yet specialized as European spas. At Glen 
Springs, New York, particular care is given to cardiovascular diseases. 
The Nauheim spring is rich in calcium chlorid, and its brine is five times 
more concentrated than that of Bad Nauheim. Springs at Saratoga are so 
numerous and so diverse in composition that the waters are especially 
suited for the treatment of many maladies, among which stress is laid 
upon digestive disorders, chronic rheumatism and sciatica. The excellent 
work of Dr. Charles G. Anthony in supersaturating the Nauheim baths 
with carbonic acid gas makes them unequaled. At Virginia Hot Springs, 
the American Aix-les-Bains, special study is given to metabolic diseases. 
The hot baths and the genial climate are grateful in myositis, sciatica, 
neuritis and rheumatoid conditions, and the radio-activity of the waters 
enhances their value. At these springs there is an excellent installation 
of Lander apparatus and physical therapy is well organized. White Sul¬ 
phur Springs, one of the most luminous health resorts in the world, has 
a splendid climate, and excellent bathing facilities. Waukesha Springs, 
Wisconsin, is given up to the treatment of severe functional disorders 
of the nervous system. 

War has made European spas inaccessible at present, and the residual 
hatred among the belligerents will long deprive the German and Austrian 
spas of much of their cosmopolitan charm. In the meantime the wealth 
of balneological resources which the United States possesses is slowly being 
realized by Americans. The authorities have begun to conserve this 
wealth, the patients to appreciate it. Foreign spas offer no therapeutic 
facilities which cannot be equally obtained, both more easily and more 
comfortably, by Americans at home. 

Unless the patient’s physical state warrants the strain of a journey 
the suggestion of a spa should not be made. Having determined that a spa 
is desirable, the physician considers the accessibility of the spa, its climate, 
its elevation above sea level, the accommodation it provides, the nature of 
the waters, the bathing, massaging, and other therapeutic facilities, and 
above all the quality of the medical care available. These considerations 
determine his choice. In weakly patients a preliminary course of treat¬ 
ment may be necessary at home before any journey is attempted. Thus, 
in severe heart cases, a modified Nauheim treatment may first be insti- 


BALNEOLOGY 


465 


tuted, by the private physician; then a home spa may be utilized in order 
to strengthen the patient for the long, rough journey, or the stormy sea 
voyage, or the rigors of the new climate, and then the possibly more de¬ 
sirable and efficacious foreign spa is attempted. Thus, in severe heart 
cases, a modified Nauheim treatment may first be instituted by the 
private physician; then a home spa may be utilized in order to strengthen 
the patient for the long, rough journey, or the stormy sea voyage, or the 
rigors of the new climate, and then the possibly more desirable and effi¬ 
cacious foreign spa is attempted. 

Climate of Spa.—As regards the climate, raw, damp, cold regions 
would naturally be contra-indicated in acute pulmonary conditions or in 
convalescence from pneumonia. High altitudes, while dry and rare and 
calm, afford greater variations of temperature and are not desirable for 
the sleepless and mentally distressed, nor should they be visited by severe 
heart cases, arteriosclerotics, apoplectics, and those with a tendency to 
hemoptysis. Then, convalescents from acute diseases, also, had better not 
be sent to mountainous health resorts. Eor all these the sea level is better, 
for the sea climate is more equable. 

The Spa Itself.—The chemical composition of the water is not a 
matter of great moment. More important are the bathing facilities, the 
provision for physicotherapy, and the housing arrangements. Unless good 
food and good accommodation are insured the spa should be avoided. 
For the slightly ill the social life of the spa is an important therapeutic 
factor. But the most essential point of all in the choice of a spa is a 
knowledge of the medical skill available. A spa, where a local physician 
is personally known to the physician who sends the case, should, if possible, 
be selected. Just as a physician would not readily recommend his patient 
to a surgeon for whom he could not personally vouch, so should he be 
chary of committing his case to the care of an unknown health-resort 
physician. Arrangements for the patient should be made before the 
journey is commenced, so that when the invalid arrives at the spa all 
unnecessary discomfort and delay may be avoided. With the patient a 
full account of his malady and its treatment should be sent. Much must 
be left to the discretion of the local physician at the health resort, but 
the family physician should know whatever is proposed for the treatment 
of the patient he sends, why it is proposed, and what it promises. Home 
spas should always be recommended whenever possible. The season at 
most spas is from May 1 till September 30. Many, however, especially 
those with thermal springs, are winter resorts also. 

Tardy Convalescence 

A patient convalescing is in a state of physical and mental instability 
and has so little reserve strength that fatiguing journeys must be avoided. 


466 


HYDROTHERAPY AND BALNEOLOGY 


All spas which practice heroic methods are emphatically contra-indicated. 
No “flushing” treatment to exhaust the heart and to fatigue the kidneys 
should he considered. A change of air alone may be all that is necessary. 
If a spa he selected it should be one in which the treatment is gentle and 
not fatiguing—a mild, near, warm, sheltered spa, at a low altitude. If 
the patient is markedly anemic a spa with iron waters or with iron and 
salt waters should be chosen. 


SPECIAL BALNEOLOGY 

Diseases of the Blood — Anemia .—It is essential, first, to consider 
whether the patient he suffering from primary or secondary anemia. In 
the primary anemia of adolescents constipation is so often a causative fac¬ 
tor that good results are frequently obtained by the use of the mild 
aperient waters of any of the saline or thermal springs. Such waters 
alone may effect a cure. But before, during, and after the spa treatment 
pharmaceutical preparations of iron may be exhibited. If a mixed salt 
and iron spring be available the treatment may be begun there and then 
finished at another spring containing more iron. Often climatic change 
alone suffices to effect a cure, and no change is more generally useful 
than that which is obtainable by a sea voyage. In the anemia which fol¬ 
lows repeated losses of blood from hemorrhoids, the mildly purgative 
springs, which tend to reduce portal congestion, are indicated. In the 
anemia due to chronic renal conditions, great care is necessary: the dis¬ 
eased kidneys are already overstrained; the demand made upon them by the 
ingestion of a great volume of fluid may complete their undoing. In the 
anemia of incipient tuberculosis, especially that complicated by hemoptysis, 
a warm, sheltered, low altitude spa is desirable. In the anemia of syphilis, 
sulphur springs, such as Aix-la-Cliapelle, are recommended. In all anemias 
it is essential, first, to recognize the underlying cause and then to choose 
the spa suited to the treatment of the primary disease. 

Diseases of the Respiratory Organs. —The main respiratory diseases 
seeking balneological treatment are chronic bronchitis and emphysema, 
asthma, and tuberculosis. Persistent traces of exudate after pneumonia 
are also often subjected to spa treatment. The essence of the treatment, 
so far as the respiratory tract is concerned, is to improve the climatic con¬ 
ditions. Bronchitis and emphysema arise from many causes—respiratory, 
renal, cardiac, vascular, etc. The cardiac and vascular, and perhaps the 
renal case, may he benefited by appropriate waters. The slight expec¬ 
torant action of the alkaline and saline waters may also directly help the 
relief of the morbid process in the lungs. For the tuberculous patients 
rest, feeding, sun and light, and fresh-air baths are necessary. 


SPECIAL BALNEOLOGY 


467 


Cardiac Diseases. —With cardiac cases careful consideration is im¬ 
perative before a visit to a spa be attempted. In severe valvular condi¬ 
tions the patient is better at home. Long journeys and bulky water treat¬ 
ment are more liable to kill than to cure. If spa treatment be contemplated 
in such cases a preliminary course of Nauheim baths (see Chronic Myo¬ 
cardial Insufficiency) should be given at home. The heart muscle should 
also be strengthened by cardiac tonics such as strophanthus or digitalis. 
Even when the valvular disease or the myocardial change be not severe 
the journey should not be rashly undertaken, and it is desirable to travel 
by short stages. 

A beginning should be made with rest after the journey. Then Nau¬ 
heim baths of short duration and about body temperature should be given. 
Gradually the baths may be cooled and lengthened. Then the carbonic 
acid gas may be added to them. Finally, the Schott exercises may be at¬ 
tempted. Later, the Oertl treatment, regulated walking, and the climb¬ 
ing of slopes, may be practiced when the heart has been strengthened 
enough to allow of its use. 

The hearts most benefited by spa treatment are the weak, fat, flabby 
hearts of over indulgence in everything except exercise. 4 The dietetic and 
hygienic regime and the graduated work often act as a charm in such 
cases. If the heart is weak, graduated exercises are very cautiously in¬ 
itiated. Passive movement alone is first attempted; next, active move¬ 
ments; then resistance movements; and, finally, the Oertl exercises. In 
the dilated fatty heart of anemia the cause of the anemia should be the 
chief object of treatment. The guiding principle should be “to hasten 
slowly.” Excessive work may damage a dilated heart so as to require 
months of treatment to remedy the indiscretion. Very little good comes 
from the ingestion of water: and positive harm may accrue if the water 
be aerated. 

Renal and Bladder Diseases. —Since the work of von Noorden and 
his school the popularity of balneological treatment in kidney diseases 
has rapidly waned. It is now generally admitted that to fatigue the kid¬ 
neys by imposing upon their already feeble energies the labor of excreting 
large quantities of fluid, is a course of very doubtful therapeutic 
wisdom. 

The cause of gravel lies in dietetic errors. No treatment should be 
instituted before the precise chemical composition of the urinary deposit 
is determined. Then rational dietetic measures are the best means to 
combat the tendency. To render the urine alkaline by ingestion of 
alkaline waters in bulk is to precipitate the urinary phosphates and to 
add a phosphatic layer to the calcareous nucleus already present. The 

4 The special indication for Nauheim treatment is chronic myocardial insufficiency 
of the first and second degree; it should never be employed in the third stage (see 
Chronic Myocardial Insufficiency).— Editor. 



468 


HYDROTHERAPY AND BALNEOLOGY 


flushing of the urinary system with waters containing small amounts of 
calcium carbonate and phosphate—the so-called earthy waters—is in itself 
harmless and of little efficacy. Equally good results could be obtained 
by drinking quantities of warm water on an empty stomach at home. 
As the cause of calculus formation is usually disease of the bladder wall, 
local medicinal treatment of proven value must not be neglected for the 
more ornamental but less useful bath treatment. 

Rheumatism. —No one would think of moving a case of acute rheuma¬ 
tism to any spa, however praiseworthy. In the prolonged convalescence 
which follows sometimes, in cases which persistently relapse slightly, 
which continue to have tender, painful joints, which show slight valvular 
or myocardial changes, or which are pronouncedly anemic, a change to a 
spa often works wonders. When joint changes are the main impediment 
to health, when thickening and effusion persist, a spa should be chosen with 
alkaline or sulphurated saline waters, a hot spa, a spa in which Zander 
exercises, massage, and good bathing facilities are obtainable, so that 
absorption of the morbid products may be hastened. When cardiac trouble 
is the residue, then Glen Springs, Clifton, Saratoga, or some other spa, 
where cardiac troubles are especially treated, should he selected. The 
anemic cases should he sent to an iron saline spring. The climate of the 
spa selected should be equable, warm, and dry. 

Alimentary Disorders.— It is among the indiscreet of habit, the people 
who work too much and eat too little, and those who eat too much and 
work too little, that the benefits of spa treatment are most pronounced. 
In the dyspeptic, the gouty, the “livery,” the spas find their most grateful 
patients. The myriad of minor ailments of alimentary origin, and of 
importance in direct proportion to the neurotic and to the financial disposi¬ 
tion of the patient, yield to the dietetic regulation of the spa. The purga¬ 
tive waters clear the channels of life from accumulations of ages. Con¬ 
stipation is not permitted; the portal circulation is stimulated to activity; 
hepatic congestion disappears, and piles and pelvic disorders are mitigated 
or banished. The gouty concretions are dissolved; the system is flushed 
clean; contributory dietetic errors are rectified; and the high specific 
gravity of the urate-loaded urine is lowered. 

Much work requires yet to he done before we can have a satisfactory 
rational basis for the treatment of the lesser ailments. Experience and 
experiment guide us to send patients with atonic dyspepsia to sources with 
hypertonic waters; to send acid dyspeptics to the mildly alkaline saline 
springs ; and to send the obese and the gouty to the sources of strong 
waters, such as Carlsbad and Marienhad. After treatment with drastic 
catharsis, prolonged rest and judicious feeding are necessary. If these 
cannot be obtained then less heroic measures should be used. 

After all spa treatment a rest in a bracing climate for several weeks 
is strongly to be advocated before recommencing the routine of life. 


REFERENCES 


469 


REFERENCES 

Anthony, C. G. Actual Values in the Nauheim Treatment, Mod. Hosp., 
Feb., 1916. 

Bader Almanach. Verlag von Rudolf Mosse, Berlin, 1912. 

Baruch, Simon. Instruction in Hydrotherapy, Med. Rec., Jan. 18, 1908. 

-Practical Application of Hydrotherapy, Philadelphia, 1897. 

-Hydrotherapy, 3d ed., 1908. 

Baumann. Wildbaeder (Akratothermen), Valentiner’s Handb. d. Bal- 
neotherap., 1876. 

Bell, A. N. Climatology and Mineral Waters of the United States, New 
York, 1885. 

Beneke, F. W. Uber Nauheim’s Soolthermen, 1859. 

Bottey, F. Traite d’hydrotherapie, Paris, 1895. 

Brachet, L. Aix-les-Bains, London, 1884. 

Brand, Ernst. Die Wasserbehandlung der typhosen Fieber, 2d ed., 
Tubingen, 1877. 

Braun, J. Lehrbuch d. Balneotherapie, 5th ed., 1887. 

Burney, Yeo. Therapeutics of Mineral Springs and Climate, London, 1903. 

-Climate and Baths of Great Britain, Committee of Royal Med. 

and Chir. Soc., London, 1895. 

Cormack, C. E. The Mineral Waters of Vichy, 1887. 

Debout, d’Estrees. A Lecture on Contrexeville, 1891. 

Delmas, P. Physiologie nouvelle de l’hydrotherapie, d’apres des re- 
cherches recentes sur Faction du froid et de la chaleur sur l’organisme, 
Paris, 1880. 

Dieffenbach, Wm. H. Hydrotherapy, New York, 1909. Contains fair 
bibliography. 

Dirup, O. Kissingen, Its Baths and Mineral Springs, 1887. 

Emond, E. Le Mont-Dore, ses eaux minerales, 1893. 

Ferris, Warren. Reduction of Obesity, Med. Rec., Jan. 22, 1916. 

Fox, R. F. Strathpeffer Spa, Its Climate and Waters, 1889. 

Freeman, H. W. The Thermal Baths of Bath. 

Guttmann, Emil. Uber d. therapeut. Werth d. Carlsbaden Muhlbrun- 
nens bei Diabetes Mellitus, Berl. klin. Wchnschr., 1880. 

Hinsdale, Guy. Hydrotherapy, Philadelphia, 1910. 

-American Thermal Springs, Med. Rec., May 1, 1915. 

■ -Comparison of the Hydro therapeutic Methods at Aix-les-Bains. 

■ -The Case at Hot Springs (private circulation). 

Kellogg, J. H. Rational Hydrotherapy, Philadelphia, 1901. Bibliog¬ 
raphy. 

Kisch, Wintemitz, Goldstein, Lersch, and others. Hydrotherapy and 
Balneology. Articles in Real Encyclopadie der gesammten Heil- 
kunde, edited by Eulenberg, Wien und Leipzig, 1894. 








470 HYDROTHERAPY AND BALNEOLOGY 

Lersch, B. Geschichte der Balneologie, Hydroposie, und Pegologie oder 
des Gebrauchs des Wassers zum religiosen, diatetischen, und med- 
izinischen Zwecken, Wurzburg, 1863. 

Lieb, C. W. The Nauheim Treatment as Given at the Glen Springs, 
Canad. Pract. and Rev., April, 1916. 

Metcalfe, R. Essays and Notes on Hydrotherapeutics, London, 1903. 

Oppenheim. Quoted by Wickman. 

Roehrig, A. Die Physiologie der Haut, experimentell und kritisch be- 
arbeitet, Berlin, 1876. 

Runge, F. Uber die Bedeutung der Wasserkuren in chronischen Krank- 
heiten, Deutsches Arch. f. klin. Med., xii, 207, 232, 1873-1874. 

Schott, A. Die Bedeutung d. Gymnastik f. d. Diagnose, Prognose, u. 
Therapie d. Herzkrankheiten, Ztschr. f. Tlierap., 1885. 

Schott, Th. The Treatment of Chronic Diseases of the Heart by Means 
of Baths and Gymnastics, Lancet, 1890. 

-The Nauheim Mineral Waters, Their Actions, Uses, and Effects, 

Eyre and Spottiswood. 1894. 

-Die Wirkungen der Baden auf das Herz, Berl. klin. Wchnschr., 

No. 25, 1880. 

Swan, J. M. Hydrotherapeutic Treatment of Chronic Disease of the 
Heart, N. Y. State Journ. Med., Aug., 1911. 

Thomson, W. H. Pathology of Chill Affecting Localized Areas of Skin, 
Med. Rec., Feb. 17, 1912. 

Yoit, C. Uber den Einfluss des Glaubersalze auf den Stoffwechsel, 
Ztschr. f. Biol., 196, 1865. 

-Uber den Einfluss des Kochsalzes auf den Stoffwechsel, Miinchen, 

1860. 

Walter, Max J. The Nauheim Treatment in Combination with the Schott 
System, Trained Nurse and Hospital Review, Eeb., 1904. 

Weber, Hermann, Sir. Article on Hydrotherapeutics in Quain’s Dic¬ 
tionary of Medicine, 2d ed., London, 1894. 

Weber and F. Parkes. Balneology and Therapeutics. Articles in Al- 
butt’s System of Medicine, London. 

Wickman. Acute Poliomyelitis, 122, authorized English translation by 
W. J. M. A. Maloney, New York, 1913. 

Winternitz, W. Hydrotherapie, in H. von Ziemssen’s Handb. d. allg. 
Therap., Leipzig, 1881. Contains bibliography. 

Winternitz and Kisch. Hydrotherapy and Balneology, Articles in Sys¬ 
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Wolf, H. E. Hydrotherapy at Home, Trained Nurse and Hospital 
Review. 

-Die physiologischen Grundlagen der Hydrotherapie der Herz¬ 
krankheiten, Ztschr. f. phys. u. diatet. Therap., xv, 1911. 






CHAPTER XII 


PRACTICAL APPPLICATION OF COMBINED METHODS OF 
PHYSIOTHERAPY 

Harry Eaton Stewart 

DISEASES AND INJURIES OF THE NEUROMUSCULAR SYSTEM 

Central Motor Neuron Lesions 

Birth Hemiplegia in Children. —Birth injuries resulting in spastic 
paralysis and retarded mental development are treated best by prolonged 
and persistent reeducational gymnastics and massage. Simple arm and 
foot placing, coupled with controlled movements aimed at placing the 
finger upon the correctly colored or numbered squares, are often used. 
Exercises of balance and slow bilateral coordination are very valuable. 
Progress then to very simple games within the mental and physical power 
of the child to grasp and perform with reasonable accuracy. Radiant 
light for ten minutes, coupled with effleurage and gentle muscle kneading, 
aids in keeping up the nutrition of the affected parts. Accurate placing 
and controlled pressure with knife and fork are useful in preparing the 
child to serve himself at the table. 

Hemiplegia Following Cerebral Hemorrhage. —From ten days to two 
weeks after the lesion has occurred or after there is reason to believe all 
bleeding has stopped, the use of through and through diathermy by the 
interparietal route, using 500 milliamperes of current of absolute steadi¬ 
ness, will greatly aid in hastening the absorption of the clot. Take five 
minutes slowly to increase to maximum, maintain this for twenty minutes, 
and use three minutes in reducing it slowly to zero. On the affected part, 
use effleurage on the flexors, petrissage and effleurage on the extensors. 
High-frequency surface applications, or diathermy from hand to shoulder 
and foot to hip, will aid in relaxing the spasticity. Reeducational exer¬ 
cises with slowly and carefully coordinated and controlled movements 
should be employed from the third week. Some very good results have 
been obtained with men at St. Elizabeth’s Hospital at Washington and 
other places by introducing games such as indoor baseball and volley 

471 


472 


COMBINED METHODS OF PHYSIOTHERAPY 


ball. A surprising amount of motor activity is often regained and the 
patient completely forgets himself in his interest in the game. The sinu¬ 
soidal or faradic current may be sparingly employed to obtain muscular 
contraction and encourage the patient to voluntary muscular effort where 
active motion is impossible. Assistive movements should be stressed, 
insisting upon the conscious motor effort on the part of the patient, even 
though his response to such effort is almost nil. 

Cerebral Degeneration.—Impaired brain nutrition due to arterio¬ 
sclerosis may at the beginning be retarded and to some extent improved. 
Cerebral diathermy may be used by applying the electrodes to the fore¬ 
head and occiput. Gentle, long-continued cerebral galvanism through 
water resistance has also been successful in treating these cases. Mild, 
general massage is a useful adjunct in improving general nutrition. Care¬ 
fully graded general exercise is valuable. 

Encephalitis Lethargica.—In the convalescent stage of this disease 
recovery of function may be hastened by massage and exercise, employing 
general petrissage and effleurage. General calisthenics and carefully 
graded mild exercises may be used. The spasticity of any muscle group 
is treated by radiant light and high-frequency. 

Cord Lesions—Infantile Paralysis.—After the acute stage has passed 
and all tenderness has disappeared from the muscles, persistent and 
long-continued physiotherapy is indicated. A reasonable degree of success 
has been attained through treatment by the separate use of several types 
of physiotherapy, but it has been clearly demonstrated that the properly 
combined use of different measures is much more satisfactory. Radiant 
light and regional diathermy are used to warm and prepare the part for 
massage and exercise. The paraffin bath or whirlpool bath may be sub¬ 
stituted for radiant light. Diathermy or high-frequency are invaluable 
aids in inducing the deep hyperemia which improves the nutrition of the 
muscles. Massage should be confined largely to petrissage and be stimu¬ 
lating in type, but not too long continued. Care must be taken to direct 
the effort to the muscle groups. The thick, fatty, fibrous layer, which so 
often overlies the muscles, may receive the major portion of the effect of 
the massage, if superficially given. Before voluntary motor responses 
are possible, the sinusoidal, wave galvanic, or interrupted galvanic cur¬ 
rent may be used. In muscle groups supplied by partly regenerated 
neurons, a fair response may be obtained by faradism, but the early insti¬ 
tution of voluntary movement is especially desirable. Muscular contrac¬ 
tion by means of carefully graded exercise is, as a rule, to be preferred 
to that obtained by electricity. If the age of the child permits, his active 
mental effort should accompany each passive movement, making it really 
assistive in type. These exercises should at first be performed, as far 
as possible, in a plane at right angles to gravity. A small block of wood 
upon which the hand or foot is strapped, .supported by castors, will permit, 



NEUROMUSCULAR SYSTEM 473 

with slight effort, a rather wide range of motion on polished or smooth 
wooden surface (see Exercises with Carriage). 

Passive Exercises 

Normal movements of each main joint of the affected part should be 
carefully carried out. Extreme caution should be used not to overextend 
muscles or muscle groups already at a physiological disadvantage and 


Fig. 1.—Passive Extension of Shoulder Joint. 

tending to be stretched by their less affected physiological opponents, as 
is often the case with the Tibialis anticus. Those groups tending toward 
contracture should be stretched several times to their physiological limit. 
The plantar and calf muscle groups usually require this care. 

Exercises with Carriage 
Arm 

Patient on chair, affected side toward the table. 

1. Abduction and adduction of arm. 

2. Elexion and extension of elbow. 

3. Abduction and adduction of the arm with movement arrested at 
different points and starting again. 

4. Small circles to the left and to the right by combined movements 
of elbow and shoulder. 

5. Have the patient lean forward so as to bring the arm in the same 
plane as the body, using large sweeping movements from the shoulder. 







474 


COMBINED METHODS OF PHYSIOTHERAPY 


6. Hand prone on carriage, abduction and adduction of the wrist. 

7. Hand with ulnar side on carriage, flexion and extension of wrist. 

Leg 

1. Patient supine, heel on carriage, abduction and adduction of the 
leg. 

2. Patient on unaffected side, unaffected leg flexed, internal mal¬ 
leolus on carriage, flexion and extension of knee. 

3. Position same—flexion and extension of hip. 

Free Exercises 
Arm 

Patient lying supine on broad table or floor, exercises bilateral to 
improve coordination. Starting position, hands to the side. 

1. Bring hands on hips and return. 

2. Raise forearms to vertical and return. 

3. Carry arms to complete abduction and return. 

4. Raise arms fore-upward, carry to above head and return. 

5. Carry arms across body and return. 

6. Bring hands sharply to shoulder and return. 

7. Carry arms to full abduction, bring hands to axilla by flexing 
elbows, extend elbows and adduct arms. 

8. Supinate and pronate the forearm. 

Leg 

Patient on unaffected side. 

1. Flex and extend ankle. 

2. Flex and extend knee. 

3. Flex and extend hip. 

Patient prone. 

Abduction and adduction of leg with knee semiflexed, rotate hip 
inward and outward. 


Back, and Hip Extensors 

1. Patient sitting, hands on hips, incline trunk forward and raise 
to vertical. Progression secured by increasing the degree of forward 
inclination of the trunk and by placing hands behind the neck or over 
head. 

2. Patient prone on table, feet strapped, raise backward and lower. 
Hands behind neck or extended over head increase the difficulty of this 
exercise. 

•>d.t oi bn'** - I 


is; 


■i si! jjittfeji’ Y'bodi 


NEUROMUSCULAR SYSTEM 


475 


Resistive Exercises 
Arm 

1. Flexion and extension of fingers resisted finger to finger by the 
operator. 



Fig. 2.—Pronation and Supination - Machine. 


2. With glove, the fingers of which are counterweighted, extension 
with hands prone, flexion with hand supine. 

3. Finger flexion machine. 

4. Finger treadmill. 

Wrist 

1. Flexion and extension abduction and adduction resisted by operator. 

2. Wrist roller machine. 









476 


COMBINED METHODS OF PHYSIOTHERAPY 


Elbow 

1. Pronation and supination, flexion and extension resisted by the 
operator. 

2. Pronation and supination machine. 

3. Flexion and extension of elbow with pulley weight machine. 



Fig. 3.—Resistive Exercises for Development of Leg Stump. 

Shoulder 

1. Operator behind patient, resisting abduction and adduction of the 
arm. 

2. Arms raised forward, operator resisting and carrying of arms 
sideward and forward. 


Leg 

1. Operator grasps dorsum of the foot with one hand and heel with 
the other and resists flexion and extension of the ankle. 

2. Grasp with one hand above the knee and the other around the foot, 
resist flexion and extension of the knee and hip. 

3. With grasp of the ankle resist abduction and adduction of the hip. 







NEUROMUSCULAR SYSTEM 


477 


In summarizing the treatment of Infantile Paralysis the following 
points should be kept in mind. Many spinal motor neurons not entirely 
destroyed may be stimulated to function years after the acute attack. 
Work on injured tissue of this type is a delicate task which should not 
be entrusted to the untrained. The danger of overfatiguing these weak¬ 
ened structures is constant. Exercise, as nearly as possible active in 
type, is better than electrically inducing contractions, and both types 
should never be combined at one treatment. Two or three movements 
of each type are sufficient at first, and the increase in amount should he 
very gradual indeed. 


Peripheral Nerve Lesions 

Muscle Nerve Testing. —Reactions of nerve and muscle become greatly 
altered in their response to electrical stimulation when any pathological 
condition is present. Electrical testing supplies us with most of our 
data for diagnosis in nerve conditions and is a most important process, 
giving information that cannot be gained in any other way. The technic 
of nerve and muscle testing should be thoroughly understood and con¬ 
siderable practice is necessary before one becomes proficient. 

The faradic and interrupted galvanic currents, in turn, are used in 
testing both the muscle and the nerve that supplies the muscle. The nor¬ 
mal muscle responds to faradism by tetanus, as the interruptions to this 
current are so continuous in character that the muscle does not have a 
chance to relax between stimuli. When the motor nerves are affected by 
disease or trauma, they lose their normal response to faradic current; in 
fact, under certain conditions this current has no power to evoke any 
response whatever. The response to galvanic current, however, is a twitch 
produced when the current is made or the circuit is closed and a slighter 
twitch when the circuit is broken, greatest at the cathode. Such are the 
normal reactions of nerve and muscle to these currents. 

The changes in response to electrical stimulation which follow trauma 
by cutting, crushing or pinching, or inflammatory processes of the motor 
peripheral nerve or its sheath are termed reaction of degeneration. This 
reaction of degeneration or a R. D.” is characterized by: 

1. Loss of faradic excitability. 

2. The following changes in the responses to interrupted galvanism: 

a. Response is sluggish and wavelike in character. 

b. The motor point is lost. 

c. The polarity response is inverted, that is, instead of the muscle 
twitch being greatest at the cathode, when the circuit is closed 
or made, it is equally great, or greater, at the anode, chang¬ 
ing the normal formula KCC > ACC to KCC — ACC or 
ACC > KCC. 


478 


COMBINED METHODS OF PHYSIOTHEBAPY 


These changes begin in a muscle, the nerve supply of which is inter¬ 
fered with from eight days to three weeks after the injury or disease has 
occurred, and become progressively greater in degree. In the normal 
muscle, the chronaxie or contraction time is very brief and the muscle 
will respond to a stimulation of 1/2,400 of a second at 100 volts. Progres¬ 
sively longer and greater stimuli are required if degeneration progresses, 
until, with one lasting 1/200 of a second, it may not be possible to obtain 
a contraction. The reaction of degeneration is a sign of marked value to 
us in that it may indicate the location of the lesion, and stage of its 



Fig. 4. —Measuring the Strength of the Muscles Governing Elbow Extension in 
a Forearm Amputation Case. 


development. P. D. is never present in a central motor neuron lesion. 
When there has been a contusion or cutting injury to some, but not all, 
of the fibers, or they have been subjected to a mild amount of pressure, 
a condition known as partial reaction of degeneration may occur. This 
condition is characterized by weakened responses to faradism, a slower 
response to galvanism, a dulling of the motor point and a diminution in 
the normal differences of polar response. In the stage of regeneration, 
voluntary motion often precedes the return of faradic excitability and a 
gradual change to normal takes place during a period of months. The 
surgical indications for nerve suture, neuroma or dense cicatricial excision 
or freeing a nerve caught in callus must be followed, if physiotherapy is 
to be effective in shortening the disability time. 






NEUROMUSCUL AR SYSTEM 


479 


Apparatus and Technic.—The muscle should first be tested with 
faradism, using a large indifferent and a small active electrode, care being 
taken not to use an amount of current which will “splash through” to 
neighboring unaffected muscles. The corresponding muscles on the nor¬ 
mal limb or on the operator may be used for control. The test with in¬ 
terrupted galvanism is most satisfactory when done by means of the 
muscle-testing condenser. This is a modification of the Lewis Jones 
apparatus, consisting of a series of galvanic condensers, of ascending 
microfarad capacity, equipped with an interrupter on the machine. The 
current is delivered at a strength of about 100 volts which is sufficient 
to overcome the resistance of the properly moistened skin. A scale vary¬ 
ing from .01 to 2 microfarads is available on this machine. 

Some preliminary warming of the part is desirable before testing. 
Radiant light and heat or the whirlpool or paraffin bath may be used 
for this purpose. Diathermy, while aiding distinctly in the nutrition 
of the part and the regeneration of the nerve and muscle, will quite badly 
mask the results of muscle testing; hence, it should be used after and 
not before such tests are to be made. With the use of the condenser, 
the normal side also is taken as a control. The active, testing electrode 
should be not over one-half inch in diameter and for the interossei and 
finer muscles must be even smaller. It is attached to the negative pole 
and applied as nearly as possible to the motor point. One condenser 
after another is turned on and the point noted at which a good response 
in muscle or tendon is elicited. A convenient chart for recording results 
of the test, as used by Captain A. B. Hirsh, at Walter Reed Hospital, 
is appended. Occasionally, in large masses of scar tissue the motor point 
may be displaced, but it is easily located with the condenser. It was found 
at Walter Reed Hospital that the test made with the condenser checked 
up well with conditions found at operation. Muscles which respond some¬ 
what to faradism will usually recover within six weeks, but a guarded 
prognosis should be made in regard to ultimate recovery. 

Earadic Galvanic 
L R L R 

Musculocutaneous 

Peroneus Longus . 

Muscles Extending Tarsus and Flexing Digits 

Tibialis Posticus 

Gastrocnemius, inner head. Name . 

Gastrocnemius, outer head . 

Tibialis posticus. Ward .Date. 

Flexor longus hallucis .. Tested by.. 

Flexor longus digitorum . Recorded by . 

Flexor brevis digitorum . Diagnosis. 

Interossei. Department No. 

Remarks: 

















480 COMBINED METHODS OF PHYSIOTHERAPY 


Faradic Galvanic 

L R L R 


Muscles Acting on Humerus 

Superascapular 

Suspraspinatus . 

Infraspinatus . 

Musculocutaneous 

Circumflex 

Deltoid . 

Teres minor . .••• 

Muscles Acting on Forearm 

Musculocutaneous 

Biceps . 

Musculospiral 

Supinator-longus . 

Triceps . 

Muscles Causing Pronation 

Median 

Pronator teres .. 

Pronator quadratus. 

Muscles Causing Flexion 

Median 

Flexor carpi radialis.. 

Palmaris longus . 

Flexor sublimis digitorum . 

Flexor longus pollicis. 

Abductor pollicis . 

Ulnar 

Flexor carpi ulnaris . 

Flexor profundus digitorum. 

Hypothenar group . 

Flexor brevis pollicis (median)... 
Adductor pollicis . 


Muscles Causing Extension 

Musculospinal 

Extensor carpi radialis longior.. 
Extensor carpi radialis brevior. . 
Extensor ossis metacarpi pollicis 

Extensor longus pollicis. 

Extensor communis digitorum.. 

Extensor carpi ulnaris. 

Muscles Acting Between Fingers 
Ulnar 

Interossei .. 

(2 Outer, Median). 

Muscles Acting on Femur 

Obturator 

Adductor longus . 

Adductor magnus (sciatic). 

Gracilis .. 

Superior Gluteal 

Tensor vaginas femoris. 

Muscles Acting on Tibia 
Anterior Crural 

Vastus internus .. 

Vastus extemus . 

Sciatic 

Biceps.. 

Semitendinosus .. 

Semimembranosus ..., 

Muscles Flexing Tarsus and 
Extending Digits 

Anterior Tibial 

Tibialis anticus . 

Extensor longus digitorum. 

Extensor proprius hallucis. 


Electrical Diagnosis at Operation. —Craus and Ingham used electrical 
testing during operations at the Cape May and Fox Hills Army Hospitals 
to identify and determine the condition of exposed nerves. The nerve 
was picked up on a curved glass rod and tested with only sufficient strength 
to produce a minimum muscle contraction. Tests were made above and 
below the lesion. Information of great surgical importance may be ob¬ 
tained in this manner. 

Treatment of Peripheral Nerve Injuries. —Great care must be exer¬ 
cised not to overstimulate regenerating nerves. Our efforts should be 






































NEUROMUSCULAR SYSTEM 481 

directed to maintaining, as far as possible, the nutrition and tone of 
muscles whose nerve supply has been interfered with. Radiant light 
and heat and gentle massage are useful in this respect. Treatment by 
means of diathermy, which, as before stated, interferes with muscle test¬ 
ing, is a most valuable part of the regime. It is now believed that a 
good deal of the atrophy which ensues in muscles whose nerve supply 
is subnormal is due not to inactivity but to over activity, caused by a 
fibrillation of the individual muscle fibers. In several cases of severe 
peripheral neuritis due to beriberi, this fibrillation was coarse enough to 
be seen. The effect of the high-frequency currents, particularly the 


Fig. 5.—Apparatus for Measuring Degree of Return in Joint Function. 

d’Arsonval, in producing sedation and arresting fibrillation, is marked. 
It is perhaps as much through this effect as that of local vasodilatation 
that diathermy has proved so useful in these conditions. The electrical 
stimulation of contraction has often been overdone and a carefully graded 
technic, such as that used by Sampson and described in the section on 
Sinusoidal Currents, is all that should be used. Overstimulation will 
defeat the aim of early regeneration and delay recovery. 

Passive motion should be maintained in all the joints moved by the 
affected muscles, and protective braces are essential to prevent contrac¬ 
tures. Progress to assistive and active exercises as returning enervation 
permits. Carefully prescribed occupational therapy should be used coin¬ 
cident with physiotherapy as soon as some active motion and strength are 
secured. 




482 


COMBINED METHODS OF PHYSIOTHEEAPY 


Neuroma. —The warm whirlpool or paraffin hath, diathermy, and, 
occasionally, positive galvanism, are useful in allaying pain. The cure 
of it is distinctly a surgical problem. 

Neuralgia.— Prolonged intense radiant light and heat, diathermy 
localized over the affected nerve and static effluve will often relieve this 
condition. All treatments should be long continued and gentle in type. 

Volkmann’s Contracture. —Good results were obtained in many of 
our army cases by the persistent use of physiotherapy. Padiant light 
and heat or the whirlpool bath, as hot as could be borne, were used for 
about ten minutes followed by zone or through and through diathermy. 
The massage should consist of effleurage, light kneading and passive move¬ 
ments. The fingers should be straightened with the wrist flexed and held 
in this position while the attempt is made to extend the wrist. 

Acute Neuritis. —In either the toxic or traumatic type of acute neuritis, 
a good general technic is as follows: Padiant light and heat, 1,500 candle- 
power for twenty minutes. Direct or zone diathermy 1,000 to 1,500 
milliamperes for twenty minutes followed by ten minutes of static effluve. 
If tender points are found, the diathermy and static brush should be 
localized as nearly as possible over them. Special care should be taken 
in going over the spinal nerve roots which supply the affected area to 
elicit tenderness. 

Snow uses static Morton wave, starting with a short, easily tolerated 
spark-gap which is widened as further tolerance is developed. In my 
hands this procedure has occasionally been very successful but often 
has increased the severity of the pain. 

Another technic, employing ionization with sodium salicylate, has been 
described in the section on that modality. . 

Frank B. Granger, of Boston, has attained good results with a com¬ 
bination of prolonged ionization or positive galvanism, together with vibra¬ 
tion to numbness of the affected spinal nerve roots. In this technic the 
solid rubber-ball vibratode is applied to the intervertebral spaces on the 
affected side, at least one minute over each nerve root. If too short 
a vibration is given, the tendency is to stimulate instead of to numb the 
pain. 

Static sparks may be used to relax associated muscle spasm but are 
more valuable in chronic neuritis. 

Chronic Neuritis. —Preliminary heat and diathermy should be fol¬ 
lowed by static Morton wave and sparks, after which slow deep effleurage 
along the nerve trunk for several minutes should be given. Sparks or 
sinusoidal current may be used freely to relieve the spasticity of neighbor¬ 
ing muscles. Ionization and positive galvanism are not as efficient in 
chronic as in acute neuritis. 

Brachial Neuritis. —Radiant light and heat should be applied to the 
nerve roots as well as to the shoulder and arm. One diathermy electrode 


NEUROMUSCULAR SYSTEM 


483 


should be placed along the affected side of the lower cervical vertebrae, 
the other may be a cuff above the elbow or the autocondensation handle 
held in the hand, depending upon whether or not the pain radiates below 
the elbow. The electrode for Morton wave is applied along the upper 
border of the trapezius muscles, to include the exit of the circumflex nerve. 
Static brush and sparks may be used freely over the entire painful area. 

Sciatic Neuritis. —The technic of the electrode application for ioniza¬ 
tion or positive galvanism is described under ionization. The radiant 
light should be applied from the sacrum to below the knee. A long narrow 
electrode extending from the sciatic notch to the popliteal space is used 
for the Morton wave application, while sparks are applied throughout 
the origin and course of the sciatic nerve. There is a steady progression 
in the vigor of the treatment from the subacute through the chronic stage. 
Chronic cases are often temporarily rendered acute, after which they 
clear up more readily, and the patient should be so informed. 

Neurasthenia. —The number of diagnoses of pure neurasthenia is de¬ 
creasing. Some organic basis for the symptom-complex termed “neuras¬ 
thenia” is now usually found, and yet, whatever the cause, there are 
certain tonic treatments of a physical type which will in most cases hasten 
recovery. Those cases associated with low blood-pressure arq treated by 
static charge, spinal vibration, increasingly vigorous massage and general 
exercises. There has been described a splanchnic type in which, due to 
poor vasomotor tone of the splanchnic veins, the systolic blood-pressure 
is higher in a horizontal than in a sitting or standing position. These 
cases seem to he benefited by the type of treatment just given, and an 
improvement in their general condition is coincident with a return to 
normal in the blood-pressure variations in the different positions of the 
body. 

In cases complicated by anemia and sluggish intestinal action, general 
progressive body-raying with the ultraviolet light and special abdominal 
massage and exercises, with Morton wave current over the liver, are 
indicated. 

The tonic type of hydrotherapy, especially short cabinet bath followed 
by Scotch douche with increasing variation of hot and cold, is very useful. 

It is justifiable to employ the psychical effect of the electrical modali¬ 
ties, when carefully chosen, as well as for definite physical effect. 

Toxic Myositis. —In the acute stage, relief is obtained by prolonged 
local heat, radiant light of high candle-power or superheated dry air, 
followed by direct diathermy or surface high-frequency, static effluve or 
mild static sparks and Morton wave, with massage consisting of petrissage 
and gentle deep kneading. 

In the chronic stage, diathermy should be pushed to tolerance. Long 
heavy sparks and Morton wave or the long stroke motor vibrator should 
follow diathermy. A surging sinusoidal current may be to some extent 


484 


COMBINED METHODS OF PHYSIOTHERAPY 


substituted for static. Massage includes tapotement, deep friction and 
kneading, the object of these procedures being to relax the muscle spasm 
and mechanically remove the accumulated toxins. Effort is made to in¬ 
stitute a greatly increased active hyperemia and then force the excess 
circulation out of the muscles, bringing about a complete change of circula¬ 
tion and depleting the toxins and detritus. 

Traumatic Acute Myositis. —These injuries are typified by the smash¬ 
ing muscle bruises received by football players and the remarkable effi¬ 
ciency of early and persistent physiotherapy has been demonstrated in 
a very large number of cases. 

The treatment of mild injuries, without much tearing of muscle fibers, 
should be begun at once or within a few hours. Fifteen hundred candle- 
power radiant light, paraffin bath, steam towels, superheated dry air or 
hot water, may be used for external heat, mentioned in order of prefer¬ 
ences. Direct through and through diathermy, 1,500 to 2,000 milli- 
amperes for fifteen minutes, should be followed by Morton wave, static 
sparks or gentle, slow, sinusoidal contractions of the involved muscles. 
It is of the greatest importance to remove the exudate from the muscles 
before it has had an opportunity to organize. 

Treatment of severe bruises, which are associated with tears of the 
muscle fibers, should be postponed a few hours, until all capillary bleed¬ 
ing has ceased. The Morton wave or sparks should be given very gently, 
if at all, on the first day. Massage should be directed, the first day, 
toward clearing out the lymphatics proximal to the lesion and not over 
the torn muscle fibers. The second and third treatments should be quite 
vigorous in regard to these measures. 

Torn Muscle Insertions.— These injuries follow sudden violent exer¬ 
tions, such as those used by the sprinter. The muscles must be completely 
relaxed in extension before the application of physiotherapy. External 
heat, direct or modified diathermy, by the combined use of autocondensar 
tion cushion and surface non-vacuum electrode, may be applied. Static 
effiuve is valuable in relieving pain and gently depleting the tissue fluids. 
No other type of static or contractile current of any kind should be used 
until the muscle attachment is again secure. Gentle, long-continued effiuve 
will relax spasm, alleviate pain and remove lymphatic stasis. 

Tenosynovitis. —This condition is most commonly found in the 
Achilles’ tendon, but sometimes elsewhere. Acute cases require absolute 
rest and superficial heat, of the kinds mentioned. Powerful radiant light 
or paraffin bath are best, or static effiuve and tiny sparks, followed by 
finger-tip effleurage, may be used. In chronic cases, the local heat should 
be intensified and longer sparks or vibration may be used to free adhesions 
between tendon and sheath and to break up and absorb any organized 
exudate that may be present. Further massage consists of frictions and 
effiuve. 


DISEASES AND INJURIES OF BONES AND JOINTS 485 


DISEASES AND INJURIES OF THE BONES AND JOINTS 

Fractures. —The treatment of fractures has been mentioned as one of 
the exceptional conditions in which the usual surgical procedures are 
modified when physiotherapy is applied. This is in reference to the 
retention of fixation apparatus. The best results are obtained when open 
fixation or bivalved casts, which may he early removed and replaced, are 
used. There is always trauma to the surrounding soft parts to which the 
application of physiotherapy is highly desirable, while the continued 
mobilization of surrounding joints is an essential feature of good frac¬ 
ture work. The actual healing time of the fragments themselves may be 
reduced fully one-third. In cases of delayed union lasting many months, 
callus has been, for the first time, thrown out after the use of physio¬ 
therapy. Complications such as osteomyelitis may usually be effectively 
treated. Far better results follow a regime of preoperative physio¬ 
therapy, after extensive injury to soft tissues where an open operation 
is necessitated. John J. Morehead, of New York, emphasizes the use of 
massage the day following reduction, and passive motion instituted as soon 
as possible after the third day. 

Simple Fractures .—Radiant light and heat is an aid to nutrition and 
to the relief of pain and may be started immediately, with gentle 
effleurage. These two measures have been extremely useful where pain 
and muscle spasm rendered reduction difficult. Very short static sparks 
and effluve may be employed for the same purpose. As soon as all ten¬ 
dency to capillary oozing has ceased, a through and through sedative 
diathermy technic should be used. This consists in giving about 500 
milliamperes for forty minutes daily. Zone diathermy through a tightly 
fitting and undivided cast may induce increased swelling and symptoms 
of pressure. It may be used above and below a splint or loose cast, but 
the direct method is to be preferred where possible. Static effluve is 
useful in relieving both pain and swelling. With the fragments firmly 
supported, gentle passive motion of the joints above and below the frac¬ 
ture should be started early and continued until active motion is possible. 

As soon as callus union is obtained, more vigorous massage, including 
deep petrissage and friction, should be used. Active motion is one of the 
most valuable measures, and must be started at the earliest possible mo¬ 
ment. Distal joints should be actively exercised from the start. Colonel 
Dean in his work with the British Army demonstrated the great value 
of active exercise. Should joint adhesions form, the use of the patient’s 
body weight may often be employed to stretch them, instead of depending 
upon the manual passive exercise. The breaking up of adhesions by vio¬ 
lent passive motion under an anesthetic is almost never necessary or 
advisable. 


486 


COMBINED METHODS OF PHYSIOTHERAPY 


In fractures near or into joints early mobility is being increasingly 
insisted upon. When, however, this is not possible, the muscle tone may 
be maintained by the use of the slow sinusoidal, faradic or galvanic wave 
currents. V.ery gentle contractions may be produced in individual muscles 
which will not involve joint movements. 

Exuberant callus may be absorbed by the use of short intensive 
diathermy treatments. Use small plates and push the heat to tolerance. 
Great care must be taken if the area is anesthetic. Frictions and vibra¬ 
tions are additional aids in callus absorption. 

Compound Comminuted Fractures .—This type constitutes a very 
large group in our army practice. The early use of prolonged radiant 
light and ultraviolet light directly on the wound is very valuable in con¬ 
trolling the amount of infection. Diathermy should be used by the double 
cuff method from the start. Slight motion of the fragments, produced by 
treatment, may not be detrimental. Later on, persistent sinuses may 
be treated directly by ultraviolet light, with the water-cooled lamp, 
through the use of sinus applicators. Massage has often brought to the 
surface a small and unsuspected sequestrum and it is useful for increasing 
tissue drainage when gently applied. 

Fractures in children complicated by rickets are treated by local and 
general ultraviolet light in addition to the other forms of physiotherapy. 

Fracture Sprains .—The linear fractures and small separations of bony 
tubercles that occur so commonly with severe sprains are better protected 
but otherwise treated by the technic for sprains later to be described. 
Where possible early active movement should be insisted upon. 

Rickets. —If there is one specific use in physiotherapy it is the use 
of ultraviolet light in this condition. The work of Hess, of New York, 
Erlacher, of Vienna, and many others shows that this method of treatment 
alone is sufficient to cure a large majority of the cases. Heliotherapy 
unfiltered through glass may be substituted for the quartz light. Treat¬ 
ment should be given daily to half of the body, the initial dose depending 
upon the type of lamp and individual skin reaction, by the principles 
already outlined. The average dose is one to three minutes at thirty 
inches, with a ten to twenty second daily increment. Periodic X-rays 
should be taken to estimate the degree of calcification. Two months is 
usually sufficient for restoration to a practically normal picture, in cases 
not too far advanced. Where quartz light is not available, heliotherapy 
should be substituted and radiant light and massage may be used in con¬ 
junction with the changes in diet and medicinal care. 

Osteomyelitis. —The work of A. B. Hirsh and C. M. Sampson, at the 
Fox Hills Army Hospital, demonstrated the value of diathermy and ultra¬ 
violet light in all types of osteomyelitis. The through and through 
diathermy, with technic arranged to concentrate the heat in the affected 
area, is the best type, where its use is possible. The double cuff or cuff 


DISEASES AND INJURIES OF BONES AND JOINTS 487 

and water method may be used where the direct double plate technic is 
impossible. The active hyperemia induced in the seat of the lesion is 
a powerful aid in arresting the infection. General ultraviolet light should 
be used, preceded by high candle power irradiation to increase the skin 
capillary hyperemia, thus augmenting the volume of the blood-stream 
acted upon by the rays, for the purpose of building up the general re¬ 
sistance. Local applications of quartz light are given, if the location of 
the infection is fairly superficial. A large surface quartz applicator is 
used with compression. Deeper-seated lesions with discharging sinuses 
may sometimes he reached through special applicators with the water- 
cooled light. 

Tuberculous Osteitis. —General ultraviolet irradiation is always in¬ 
dicated in tubercular bone disease. Local applications are useful, if the 
lesion is sufficiently superficial to he reached by compression. The em¬ 
ployment of diathermy will increase the phagocytes where most needed, 
and its method of application depends upon the location of the process. 

Periostitis. —Simple periostitis is treated with radiant light and heat 
or paraffin bath followed by high-frequency, static effluve and gentle 
effleurage. When periostitis is complicated with spur formation, as is 
common in the os calcis, the inflammatory process and consequent dis¬ 
ability may he greatly relieved. Occasionally, newly formed spurs may 
be to some extent absorbed. There is often little correlation between the 
size of spurs and the physical discomfort they produce. Intensive external 
heat is used if the process is superficial. If deep seated, give direct 
diathermy with heat localized by using a small plate over the lesion. 
Static sparks sometimes greatly relieve the pain and are used after 
diathermy. 

Traumatic Arthritis. —This type of injury is especially amenable to 
treatment by physiotherapy. In the acute stage, where there is practi¬ 
cally no rupture of ligaments, active hyperemia may he induced by the 
hot paraffin or whirlpool bath, strong radiant light, high-frequency or 
diathermy. This should be followed by static sparks, directed not only 
around the joint surfaces but to such muscles as may he in a state of 
protective spasm, proximal to the sprain. This is followed by prolonged 
gentle massage employing, for the most part, frictions and effleurage, 
carried well above the injured joint. 

Active use of the joint, protected against stretching of the affected 
ligaments, is indicated from the start. The results of thorough and im¬ 
mediate treatment by this technic are extremely satisfactory. In severe 
sprains associated with extensive laceration of ligaments, intensive local 
external heat is indicated, followed by static effluve and gentle effleurage, 
the main effort being to clear out the lymphatics above the sprain, thereby 
increasing the tissue drainage. The second or third day direct diathermy 
may be employed, using plates of different sizes to localize the heat in the 


488 COMBINED METHODS OF PHYSIOTHERAPY 


tom ligaments, while gentle frictions are begun directly over them. 
Passive and active motions are used to an increasing degree, applied in 
such a way as not to bring tension on the torn structures. After several 
days, static sparks may be used around, but not over, the affected liga¬ 
ments. Vasomotor stimulation, by plunging the foot alternately into hot 
and cold water, is a useful stimulant. Where there is excessive effusion 
into the joints, the Morton wave for about twenty minutes should be 
given, followed by sparks. In the case of the knee, a blunt U-shaped 
electrode may he applied so as not to include the patella. This procedure 
has often been so efficient in removing non-hemorrhagic fluid from the 
joint that aspiration was unnecessary. 

Toxic Arthritis. —Symptomatic relief and temporary improvement 
may be secured by treatment before the focus of infection has been elimi¬ 
nated, but the results are naturally greatly accelerated afterwards. Where 
persistent search has revealed no source, long-continued treatment will 
often completely clear up the local joint manifestation. The patients 
should he warned of the temporary exacerbation of the joint condition 
which often follows removal of infected tonsils or teeth. After such 
removal accelerated recovery is the rule. 

The technic used consists in superficial heat by means of radiant 
light, superheated dry air or paraffin hath, direct diathermy, static Morton 
wave and sparks and massage, largely effleurage. A hydrotherapeutic 
application of hot whirlpool bath followed by cold pressure douche has 
been used. Relative rest of the joint is indicated. 

Arthritis Deformans. —This condition has proven resistant to all 
types of therapy and yet under modern attack is by no means a hopeless 
one. The accepted conception of the etiology requires that the physio¬ 
therapeutic treatment be directed both at the eliminative mechanism and 
the joint symptoms. It has been the rule that those joints involved for 
a period of not over a year yield rather readily to intensive treatment. 
The dietary regulation, search for focus of infection and correction of 
the entire regime of the patient, must be attended to with more care 
than is necessary in most other conditions. 

General body irradiation with the air-cooled quartz light, static wave 
over the liver, and deep abdominal massage and exercises should be given 
while the local conditions are being treated. The affected joints are 
treated by 1,500 candle-power radiant light, paraffin bath or other local 
heat, with high-frequency pushed to tolerance, or diathermy. If several 
joints of both upper limbs are involved, an autocondensation handle may 
he used from both d’Arsonval terminals. Massage—largely frictions and 
effleurage—or mechanical vibration are used. Static sparks are useful 
in the early stages of joint involvement. 

This has the appearance of being a “shotgun” prescription, but each 
modality is aimed at a perfectly definite indication. Where it has been 


DISEASES AND INJURIES OF BONES AND JOINTS 489 


faithfully followed out, the results have been almost uniformly to arrest 
and improve the condition. 

Gout. —In the acute stage, no measurable effect can be produced on 
the constitutional symptoms. Locally intense radiant light, paraffin or 
whirlpool bath relieves the local pain. W. J. Turrell has obtained good 
results with diathermy, but calls attention to the fact that an exacerbation 
of the general symptoms often follows intensive local diathermy due, 
he believes, to reabsorption and the deposits from the involved joints. A 
good technic for the application of diathermy is with the patient prone, 
his toes in saline containing one electrode, the other electrode applied 
as a cuff above the ankle. Static brush and small sparks, following local 
heat, will relieve pain and hasten absorption. Positive galvanization has 
been used in the chronic stage. Here, too, static sparks may be used to 
tolerance, following the application of local heat. 

Infectious Arthritis. —This type of arthritis, as typified by gonococcal 
infection, has shown limitations, both of the disability time and in the 
amount of joint destruction, in a very large number of cases in one of 
our Marine Hospitals. We used, in this group, the following technic. 
In joints very acutely tender, where manipulation or the slightest pressure 
was unbearable, very prolonged radiant light was applied to the entire 
circumference of the joint. In bed cases, the 100 candle-power light 
on a stand was fixed some thirty inches from the patient and applied 
for a number of hours. In the subacute stage intensive through and 
through direct diathermy was given, cross-firing the joint where possible 
from two different directions. We used about 1,500 milliamperes for 
forty minutes. The gonococcus is rather readily destroyed by high tem¬ 
peratures and it is believed that both radiant light and diathermy not 
only inhibit the growth but, to some extent, actually destroy the organism. 
No massage or manipulation of any kind should be employed in this stage. 
Cumberbatch mentions the fact that, occasionally, the galvanic current is 
more sedative than diathermy, and we found this true in several of our 
cases. 

In the chronic stage, massage, consisting of frictions and effleurage, 
and active and passive motions are used with increasing vigor. There 
was not available a static machine in this group of cases, but in others it 
has been used in the chronic stage, in the form of sparks, with consider¬ 
able success. The effluve is useful also in the subacute stage. 

Tuberculous Arthritis. —This presents a somewhat different problem. 
Applications of intensive radiant light and diathermy are here coupled 
with general and local irradiation by ultraviolet light. Local treatment 
is given with gentle compression only over those affected joints which 
are fairly superficial. The general treatment should be pushed as fast as 
tanning will permit, dividing the body into two segments front and 
back, in those who tan readily, and four with those who do not. After 


490 


COMBINED METHODS OF PHYSIOTHERAPY 


maximum irradiation of about twenty minutes daily has been reached 
and continued two or three weeks, it is advisable to reduce the time to 
five minutes and with one minute daily increment work up to maximum 
and repeat. 

Bursitis. —In the acute stage, radiant light and heat, through and 
through diathermy or surface high-frequency are followed by static effluve. 
In the subacute and chronic stage, static sparks, Morton wave and fric¬ 
tional massage are added. Passive exercise of neighboring joints should 
be used from the start. Active movements should be instituted early in 
the subacute stage and increased to full range as soon as decreasing pain 
permits. Bursae casting a dense shadow by X-ray have returned to normal 
after several weeks of treatment. 

Combined Conditions. —It is quite usual for both toxic and traumatic 
inflammation in the main joint regions to find more than one tissue 
involved in the process. It may be the joint and bursae only, or near-by 
nerve trunks and muscles may also be affected. The diagnosis is usually 
made according to the structure which is most involved in the inflamma¬ 
tory process. The treatment is somewhat similar and its minor variations 
are determined by the main indications as given for these conditions, 
separately considered. 

DISEASES OF THE CARDIOVASCULAR SYSTEM 

Hypertension and Arteriosclerosis. —In simple hypertension, auto- 
condensation has proved of value. To obtain good results the use of a 
well-constructed autocondensation mattress and the larger type of better 
made machine are essential. The small, folding electrodes and light 
portable type of apparatus will not give satisfactory results. A careful 
record should be kept before and after each treatment. It has been the 
rule to secure a temporary reduction of systolic pressure of be¬ 
tween 8 and 20 mm. Hg. between the beginning and end of a single 
twelve-minute treatment. 1 The pressure reading will generally re¬ 
turn to within 2 to 5 mm. Hg. of the former reading, before the next 
treatment, leaving a small permanent gain each time. Both the 
reduction secured during the treatment and the amount of net gain re¬ 
tained between treatments steadily lessens as the normal systolic pressure 
for that individual is approached. It should be stated that Turrell and 
one or two others do not believe that a permanent gain can be secured 
by means of autocondensation. The average degree of improvement stated, 
however, is the result of personal experience and that of many others 
in this field. 

The initial cause of the hypertension remaining, there is a constant 


1 A systolic range of from 8 to 20 millimeters of mercury is quite usual in hyper¬ 
tensives without any treatment whatever, or under varied forms of treatment.— Editor. 



DISEASES OF THE CARDIOVASCULAR SYSTEM 491 


tendency for the patient without treatment to return to his former condi¬ 
tion. Generally speaking, the hypertension may he kept down, after it 
has once been reduced to approximately normal, by periodic treatments, 
varying from one week to two months apart in different patients. 

The patient is placed in a reclining position on the autocondensation 
mattress, attached to one pole of the d’Arsonval current. A steel cylinder 
or non-vacuum autocondensation rod is held lightly, hut firmly, in both 
hands. The hands should be held free from the body by placing a small 
pillow beneath them. Better results follow the application of the cur¬ 
rent for twelve to thirty minutes, at 500 to 800 milliamperes, than in 
stronger amounts or for a shorter length of time. 

Another quite satisfactory technic is a combination of body-cabinet 
radiant light baths for ten to twenty minutes followed by a. warm shower, 
tub or mild Scotch douche. Body exposure in the reclining position to 
superheated dry air for one-half to one hour, followed by several hours 
of rest in bed, after the technic of Byron Sprague Price, of Yew York, 
has also secured good results. The application of surface high-frequency 
along the spine is recommended by some, but its effects are not as efficient 
as those obtained with autocondensation or hydrotherapy. Again the 
reader is reminded that all types of static, particularly brush and charge, 
are contra-indicated in any marked degree of hypertension. 

Arteriosclerosis, with its associated hypertension, is a much more 
difficult problem. For the adequate supply of nutrition to reach the tissues 
through thickened blood-vessel walls, a certain amount of hypertension is 
essential. If this tension is lowered too quickly or to too great a degree, 
dizziness, weakness and other unpleasant symptoms occur. While it is 
true that, with real sclerosis, hypertension does not come down as quickly 
or as far as in the simple type, I have several times seen it reduced below 
this level of safety. 

Autocondensation, therefore, should be used with extreme care in an 
attempt to lower the blood-pressure somewhat ; at least to below the point 
of immediate danger from cerebral hemorrhage. Keep careful track of 
the patient’s general feeling and condition, as well as the pressure find¬ 
ings, making no attempt to reach the degree of pressure considered normal 
for the patient’s age. Occasional cases will be found in which the pres¬ 
sure cannot be lowered, and some cases have been reported in which there 
was an apparent, rise following treatment. Light general massage con¬ 
sisting of effleurage and petrissage and mild general exercises are indi¬ 
cated for their general effect upon metabolism. Sedative baths, simple, 
aerated or medicated, may also be employed. 

Hypotension. —Some phases in the treatment of this condition have 
been discussed in its common association with neurasthenia. Static charge, 
spinal vibration, general massage and graded exercises, increasing in 
vigor, have a distinct effect in raising systolic blood-pressure. The tonic 


402 


COMBINED METHODS OF PHYSIOTHERAPY 


contrast, Scotch douche, especially to the spine, increasing the variation 
of temperature, will often accomplish the desired result. 

Phlebitis.—This is one of those conditions in which the intense pain is 
difficult to allay with ordinary medical and surgical procedures. Not 
being ambulatory, there are few cases reported in physiotherapeutic litera¬ 
ture. As before mentioned, this is one of the few conditions in which 
diathermy has been named as a contra-indication by most writers. The 
results attained by its use, however, in a number of recent cases, has led 
me to doubt whether there is any real contra-indication to the employment 
of this modality. Radiant light from an ordinary hand lamp, with or 
without the stand, applied to tolerance directly over the affected veins, is 
distinctly analgesic. We have followed this application by diathermy, 
given by the double cuff or plate, or the zone method, used above and 
below the affected part. The superficial or edge effect of diathermy so 
applied is of distinct value. In inflammation of the internal saphenous 
vein, the commonest site of phlebitis, a flexible, metal-plate electrode is 
placed on the inside of the thigh, the other on the inside of the ankle, 
and about 500 to 1,000 milliamperes of current are given, for from twenty 
to forty minutes. The relief from pain in these cases has been very 
marked, and it is difficult to see how there is any danger of producing 
embolism. No manipulations of any kind should be employed in any 
stage of this disease, preceding organization. 

Endarteritis Obliterans.—It is probable that we have at hand no 
means of curing this condition. It may, however, be retarded and ar¬ 
rested, for a time, by the use of physical measures. Any degree of 
arteriole and capillary dilatation obtainable will allow an increased amount 
of serum, rich in nutriment, to pass through into the tissues. Such super¬ 
ficial dilatation can be secured by the whirlpool bath, paraffin bath, etc. 
Dilatation of the deeper capillaries is certainly obtainable by direct 
diathermy. As a rule, however, in these conditions, some modification 
of zone diathermy technic must be used. Occasionally diathermy increases 
the pain. It is not safe or advisable to give more than 1,000 milli¬ 
amperes. The so-called vasomotor gymnastics, obtained by the use of 
contrast baths, or the contrast Scotch douche, are also beneficial. 

Anemia and Chlorosis.—It has been stated before that the effects of 
physical agents, especially light, on the blood count and hemoglobin per¬ 
centage have varied in the hands of different investigators. The pre¬ 
dominating opinion is that improvement follows where heliotherapy or 
quartz light and general tonic treatment are employed. 

Heliotherapy, where the climate permits, is administered by direct 
exposure of the entire body to the unfiltered rays of the sun, beginning 
with fifteen to thirty minutes and progressing to from one to three hours, 
as tanning permits. The average daily increase in time is five to ten 
minutes. 


DISEASES OF THE CARDIOVASCULAR SYSTEM 493 


Ultraviolet light, when available, is a more certain aid. The anterior 
and posterior portions of the body may be exposed on alternate days or, 
in those who tan poorly, the chest, back and the anterior and posterior 
surface of the extremities may be irradiated in turn. The air-cooled 
lamp is used. The initial distance is thirty inches with the mercury- 
tungsten and eighteen inches with the all-mercury burner. The average 
time is a minute and a half, with ten seconds daily increment, with the 
former type of burner, and three minutes, with a fifteen-second increase, 
when using the latter type. A maximum time of thirty minutes is suf¬ 
ficient, maintained one week. It is better then to drop back to 25 per 
cent of the dose and repeat. 

The tonic hydrotherapy with fan douche, general massage and easy 
graded exercises are available adjuncts to phototherapy in the treatment 
of this condition. 

Organic Valvular Lesions of the Heart. —In the section on the 
physiology and therapeutic application of exercise, the behavior of the 
normal heart under exertion and the use of exercise in training the nor¬ 
mal heart to maximum efficiency were discussed. The work of 1 Halsey, 
Barringer and Wilson, of Hew York, on the exercise tolerance of children 
with organic heart disease has done much to allay the fear of its employ¬ 
ment in these conditions and, still further, it points to exercise as perhaps 
our most potent therapeutic agent in the treatment of these conditions. It 
is the consensus of opinion of these writers and also of others that heart 
failure in organic disease is practically never due to physical exertion but 
to reinfection. Their combined work covers several hundred cases sub¬ 
jected to graded exercise and there has been improvement in nearly every 
case. 

The heart working against organic disadvantage compares well with 
the normal heart in its tolerance to exercise, unless its reserve power is 
low. Several types of exercise-test and regime were employed. (1) Walk 
one hundred yards on level ground in two minutes. (2) Climb stairs 
with ten-foot rise in twenty seconds. A simple test, available anywhere, 
consisted in swinging two iron dumb-bells from overhead to between the 
feet and returning at the rhythm of thirty times a minute. The dumb¬ 
bells used weighed from two to ten pounds each and this exercise was 
repeated ten to forty times starting with the lighter weight and the 
lesser number of times and gradually increasing the severity of the 
exercise. 

The points to be noted, in judging the effect of exercise, are: 

1. The appearance of the face, as regards flushing, and signs of 
fatigue and strain. 

2. The respiration. 

3. The time required for the pulse to return to normal. 

4. The systolic blood-pressure rise. 


494 


COMBINED METHODS OE PHYSIOTHERAPY 


Barringer states that a rise of 20 mm. Hg., without other indications 
of strain, is a favorable sign and emphasizes the fact that no exercise 
other than sitting up should be attempted for a week or ten days after 
an acute attack has ceased and the temperature has become normal. Hal¬ 
sey concludes that graded exercise may be given to children with organic 
heart disease, improving the action of the heart. 

In a large group of cases, May G. Wilson made some interesting ob¬ 
servations on the exercise tolerance of children with a variety of cardiac 
defects, comparing them with the tolerance of the normal children. The 
results of her tests were as follows: 

Tolerance to exercise is roughly grouped as good, fair or poor. 

Twelve with congenital malformations—all good. 

Thirty-six mitral insufficiency—twenty-three normal, thirteen fair. 

Twenty mitral stenosis—twelve normal, eight fair. 

Two with aortic regurgitation and mitral stenosis—both normal. 

Six with chronic valvular insufficiency—poor, improving steadily with 
exercise. 

Nineteen with apical systolic murmurs—eighteen normal, one poor. 

One hundred and sixteen organic cases under treatment—three died, 
one with tuberculous complications and two from acute myocarditis fol¬ 
lowing tonsilitis. 

Other forms of simple graded exercises would undoubtedly attain sim¬ 
ilar results. These are the types of cases in which it has been quite the 
rule to proscribe all exercise. The value of exercise in organic heart 
disease, especially in the young, should no longer be in doubt. Certainly 
exercise should seldom be proscribed in functional cases. 

Myocarditis. —Graded exercises, light in type and brief in duration, 
such as those described for valvular lesions, are indicated in this condition 
as well, with a careful checking up of the associated physical findings. 
This is one of the few cardiac conditions in which the results of the ap¬ 
plication of diathermy have been distinctly beneficial. Elexible composi¬ 
tion plates, about five by seven inches, are used anteroposterially. It is 
essential to have a steady current which must be applied very gradually. 
From five to seven minutes should be used in raising the current to maxi¬ 
mum of 500 to 600 milliamperes which is maintained for twenty minutes, 
using in addition four minutes in which slowly to reduce the strength of 
the current. Relative rest should be insisted upon for at least two hours 
after the treatment. Its effect upon the coronary circulation brings im¬ 
proved nutrition of the heart fibers. 

Intermittent Claudication. —Griinbaum, of Vienna, reports suc¬ 
cess in eight cases of this condition, treated by a technic of direct di¬ 
athermy similar to that just described, extending over a period of four 
to eight weeks. These cases were mild in type and his results were uni¬ 
formly good. 


DISEASES OF THE CARDIOVASCULAR SYSTEM 495 



Functional Cardiac Disturbances. —In our Army Hospital at Lake- 
wood, Hew Jersey, and at Walter Reed Hospital, in Washington, a very 
large group of cases of this type were treated. They were variously 
classified as tachycardia or effort syndrome and were similar to those 
classified “D. A. H.” of the British Army. The work at Walter Reed, 
under the direction of the chief aide, Mary McMillan, and her assistants, 
has been reported in detail by Lt. Col. Burt W. Carr, now Supervisor of 
Physiotherapy for the U. S. Veterans’ Bureau. These patients were 
treated with systematic graded exercises, largely of the rhythmic type, 


• Fig. 6.—Cardiovascular Class in Army Hospital. 

checked up with constant observation and blood-pressure and pulse find¬ 
ings. The list of exercises was divided roughly into five groups: 

1. Passive and assistive exercise, generally in the horizontal position. 

2. Active, slow rhythmic movements, prone or standing. 

3. Active movements with coordination. 

4. Active movements including both speed and coordination. 

5. Walking, running and indoor baseball and other light games. 

The patients were thoroughly examined and assigned to an appropriate 
grade of work. In case of any doubt they were placed in the next lower 
grade. Those admitted to Grade 1 were, as a rule, under nervous tension 
with high pulse rate and very apparent effort syndrome. The exercises 
were given in slow rhythm, associated with respiratory movements, and 
given in a low and monotonous tone of voice. Frequent rest periods with 
complete relaxation were taken. Careful examination was made upon 





49G 


COMBINED METHODS OF PHYSIOTHERAPY 


the least sign of distress on the part of the patient. The lessening of the 
accelerated pulse rate, in practically this entire group, was remarkable 
after exercise and was found to be still lower an hour later. The exercises 
included in Grade 2, which was one of the largest groups during most 
of the time, were as follows: Patients supine on mats. 

1. Arms extended sideward. Slowly supinated during inspiration, 
pronated during expiration, repeated twelve times. 

2. Arms at sides. Inhale and abduct thighs. Exhale and adduct 
thighs. Repeat. 

3. Hands loosely on chest. Inhale and extend arms at sides. Re¬ 
verse and repeat. 

4. Inhale and draw up knees. Reverse and repeat. Slowly assume 
standing position. 

5. Hands loosely clenched, on chest. Inhale, bringing arms to sides. 
Reverse and repeat. 

6. Inhale, raising thigh with knee bent. Exhale, extending leg, in¬ 
hale lowering foot to floor about twelve inches in front of the other. Ex¬ 
hale, bringing foot back even with the other. Repeat. 

7. Hands on hips. Inhale, bending body forward. Reverse and re¬ 
peat. Head up all the time. 

Statistics compiled by Lt. Col. Carr from Grades 2 and 3 showing the 
average improvement during a single week are significant. 


Improvement Statistics for Week 


Grade 2 

Average Pulse Rate 

Sitting 

Standing 

July 28 



Before exercise. 

85y 3 

102^ 

After exercise. 

80 

93 

August 5 



Before exercise. 

81 Vi 

91 

After exercise. 

79 

84^ 


It is interesting to note that before exercise on July 28 the pulse 
rate was increased twelve beats by standing, and after exercise thirteen 
beats, and on August 5 the increase was but nine and one-third and five and 
two-thirds. 

This decrease in pulse rate following exercise was practically con¬ 
stant. A few organic cases with normal heart rates were included in the 
averages which makes the gain in the functional cases all the more strik¬ 
ing. One case is of especial interest: Lieutenant Colonel B.; Diagnosis 













DISEASES OF THE CARDIOVASCULAR SYSTEM 


497 


“functional cardiac disorder/’ He was dyspneic, nervous and his tachy¬ 
cardia was greatly exaggerated on the slightest effort. 

July 16—pulse sitting 116, standing 130. 

July 28—pulse sitting 72, standing 75. 


Improvement Statistics for Week 


Grade 3 

Average Pulse Rate 

Sitting 

Standing 

July 28 

Before exercise. 

85V 2 

98 

After exercise. 

84 

92 

August 5 

Before exercise. 

86 

92 

After exercise .. 

82 

86i/ 2 


During the summer he was able to take part in indoor baseball and 
other games. 

Shott-Nauheim Exercises.—This is a group of slow resistive exercises, 
given with the object of strengthening the cardiac muscle, lowering the 
pulse rate and improving the entire cardiovascular adjustment. These ex¬ 
ercises are divided roughly into arm, trunk and leg movements, given, 
resisted by the operator, the patient standing. The operator resists shoul¬ 
der abduction and adduction, flexion and extension, abduction and adduc¬ 
tion in the horizontal plane, and flexion and extension of the elbow. He 
then resists trunk bending to the right and left and flexion and extension 
of the hip, knee bent and knee extended. Considerable effort is required 
in the maintainance of the erect position. In addition, much more enters 
into the resistive leg movements than the effort involved in their simple 
execution, because they require, in many cases, balancing on the other leg 
during the entire time of the slowly executed movement. Resistive exer¬ 
cises, in which class all of these fall, have been grouped as the most severe 
of the four types classified. As illustrated in numerous texts, these dis¬ 
advantages are at once apparent and the writer believes that this type of 
exercise will be entirely superseded by the newer methods just outlined. It 
is easy to understand that even a single one of these leg resistive balanc¬ 
ing movements might be too strenuous for a large proportion of the type 
of cases we had in the army. Contrast the severity of a single one of these 
movements with that of an entire group of bilateral slow, rhythmic joint 
flexions and extensions done as passive, assistive or even active exercises, 
with the patient lying supine. Nearly every single leg exercise of the 
Shott-Nauheim group would be strenuous enough to fall into Grade 3 of 
our army classification. 














498 


COMBINED METHODS OF PHYSIOTHERAPY 


DISEASES OF THE GASTRO INTESTINAL TRACT 

Pyorrhea and Apical Abscess. —The perfection of a variety of curved 
quartz applicators now permits of the direct application of ultraviolet 
light from the water-cooled lamp with compression upon all parts of the 
gums. Spongy, bleeding gums, with pyorrhea, yield very quickly, as a 
rule, to ultraviolet exposure. A narrow tipped, curved applicator is ap¬ 
plied to the dental margin, with firm compression. The initial time is 
from forty to eighty seconds with a ten or fifteen-second daily increment. 
The site of an apical abscess, located by the X-ray, may be treated an¬ 
teriorly and posteriorly in the same way, and subsequent X-rays have 
clearly demonstrated that, in many cases, the active condition has been 
eliminated. From six to twelve treatments are usually required. 

Gastritis. —Bordier and Setzu both found that diathermy, applied 
to the stomach, has a constant and uniform stimulating action on both the 
motor and secretory gastric functions. In both chronic and acute gas¬ 
tritis, the relief of pain is greater than that which might be secured by 
the application of any external form of heat. A careful diagnosis, to 
rule out malignancy or ulcer, is essential, since diathermy is contra-indi¬ 
cated in both these conditions. Treatment should he given by means of 
fairly large flexible metal plates, perhaps seven by nine inches, applied 
anteroposteriorly over the gastric area, using 1,000 to 1,800 milliamperes 
of current for twenty minutes. 

Cholecystitis. —There have been many reports upon the favorable 
effect of diathermy in thinning inspissated bile. During the passage of a 
small calculus, the relaxing and analgesic effect of diathermy is of dis¬ 
tinct value in aiding the passage of the calculus into the intestine. It is 
not believed that diathermy can have any effect in causing the absorption 
of calculi once they are formed. Diathermy should be applied antero¬ 
posteriorly by the direct method, over the gall-bladder area. As is the 
case in all abdominal diathermy, fairly strong currents must be used, 
because of the low resistance of the tissues, if any great degree of in¬ 
ternal heat is to he produced. Functional hypo-activity of the liver 
may be greatly stimulated by the twenty-minute application anteriorally 
of the static wave over the entire hepatic region. 

Appendicitis. —In the initial inflammatory stage, before the formation 
of pus, direct diathermy has apparently aborted many cases. The most 
careful checking up of the blood count with the pulse and temperature is 
essential, so that delay in the application of surgical relief will not oc¬ 
cur should pus be formed. In the preliminary stage mentioned, twenty 
minutes application of the 1,500 candle-power radiant light, followed by 
direct diathermy, 1,500 to 2,000 milliamperes for the same length of 
time, is advised. 


DISEASES OE THE GASTROINTESTINAL TRACT 499 

Gastric and Duodenal Ulcers. —Temporary relief from pain may be 
obtained through the application of radiant light. Some writers believe 
that the body raying with ultraviolet light is an aid in the healing process. 
There are certainly no contra-indications to its use. The application of 
diathermy, enthusiastically recommended by some, impresses the writer as 
containing an element of danger of hemorrhage which it is difficult to 
guard against, and it should be applied, if at all, with extreme caution. 
With improved technic it may be possible in the near future to reach 
ulcers in the lower part of the colon by the direct application of ultraviolet 
light. 

Visceroptosis. —This condition when associated with general neuras¬ 
thenia, lordosis or chronic constipation should receive treatment for the 
combined conditions. The treatment of the visceroptosis consists largely of 
abdominal massage and the following exercises: 

1. Hands palms down under hips. Flex both knees to chest, extend 
knees slowly and repeat. 

2. Itaise both legs to vertical, knees extended; lower slowly and 
repeat. 

3. With arms extended overhead, feet fixed under any convenient 
object, whip arms forward and sit up and return. Repeat. 

Progression in the severity of this last exercise is attained by per¬ 
forming the exercises next with the arms at the sides, then behind the 
neck and last with arms overhead but lifted with the body, instead of 
actively assisting the movement as was done in the first place. General 
progression should proceed from an initial start of three or four repeti¬ 
tions of each movement to twelve or sixteen of each. The abdominal 
massage consists of circular, deep kneading, covering the entire surface 
of the abdomen. 

Chronic Constipation. —To obtain a satisfactory result in the treat¬ 
ment of this usually resistant condition, every mode of attack at our com¬ 
mand must be followed. The diet, habit-time factor and occasionally 
medicinal aid must all be employed with physiotherapy. In cases where 
the underlying cause is adhesions, the physiotherapeutic treatment to be 
outlined cannot be expected to attain a cure. However, the development 
and toughening of the abdominal musculature and improvement in the gen¬ 
eral condition, which usually follows its application, is a distinct asset, 
if operation should be found necessary. These measures would be dis¬ 
tinctly contra-indicated when the underlying cause is inflammatory in 
nature, although in this case a course of direct abdominal diathermy, in 
place of the treatment outlined, might relieve the condition and make 
operation unnecessary. The treatment of simple chronic constipation 
consists in the use of a combination of exercises, massage and electro¬ 
therapy. 


500 


COMBINED METHODS OF PHYSIOTHERAPY 


Exercises .—The four exercises just outlined for visceroptosis are use¬ 
ful. Tlieir object is alternately to increase and decrease intra-abdominal 
pressure, thereby stimulating peristalsis. The following abdominal and 
trunk exercises should also be used in connection with the foregoing group. 

1. Stride, stand, arms horizontal, or hands on hips. Trunk to the 
right, bend, straighten, to the left bend, straighten, and repeat. 

2. Trunk to the right turn, return, to the left, turn, return and 
repeat. 

3. Trunk forward lower, raise, gently backward, bend, straighten, 
and repeat. 

Massage .—This consists of deep pressure movements following the 
course of the large intestine. The patient should lie supine, knees flexed 
and abdominal wall completely relaxed. The operator places one hand 
above the other, finger tips on the right lower quadrant. A series of 
four or five deep circular movements with firm gentle pressure arc 
given over the cecum. The hands are lifted and replaced two or three 
inches higher on the ascending colon. This procedure is repeated through¬ 
out the entire course of the large intestine. With the hands in the same 
position, using the entire palmar surface, deep, slow stroking is done also 
along the full course, of the colon. Walking, golf, volley ball and similar 
general exercises, are indicated. 

Electrotherapy .—The musculature of the abdominal wall and, to some 
extent, that in the walls of the intestines may be stimulated to increased 
action by the contractile electrical currents. The surging sinusoidal or 
wave galvanic currents, twenty to thirty waves to the minute for twelve 
minutes, are best for this purpose. One electrode, about six by nine 
inches, is placed over the lower dorsal and lumbar spine, the other on 
the abdominal wall. A slow, deep, current wave with voltage to tolerance 
and a distinct rest period between contractions is indicated. Uncom¬ 
plicated cases of many years’ duration have been made practically normal 
by this combined treatment. Some writers employ the static wave over 
the liver and also on the abdominal wall. Attention should be directed 
to the associated conditions so often present. Among these are neuras¬ 
thenia, visceroptosis, faulty posture and the general effects of sedentary 
living. 

Sigmoid Impaction. —This condition, when due to atonic conditions of 
the musculature of the lower bowel, may be treated along the lines just 
given and, in addition, internal rectal application of one electrode, the 
other being placed on the lower abdominal wall. Either the sinusoidal 
or wave galvanic may be employed. The lower bowel should be thoroughly 
cleaned out before treatments. In cases due to sphincteric spasm, treat¬ 
ment by diathermy, using one rectal and one abdominal surface electrode, 


DISEASES OF THE RESPIRATORY SYSTEM 501 


is advisable. Either the non-vacuum or vacuum glass electrode may be 
used. Four to six hundred milliamperes of current should be given for 
from fifteen to twenty minutes. 

Hemorrhoids and Anal Fissures.— The technic perfected by William 
L. Clark, of Philadelphia, in the treatment of these conditions by desicca¬ 
tion has been extremely successful. Desiccation has many points in its 
favor over the use of the cautery. The monopolar Oudin current is used. 
This current is applied by means of a needle attached to an insulated 
handle and connected by an insulated wire to the high-frequency ap¬ 
paratus. Small hemorrhoids are treated by fulguration with a short spark 
jump through the air. Contact is used on medium-sized and direct in¬ 
sertion in the larger veins. Local novocain anesthesia is used inter- 
muscularly. In treating external hemorrhoids, Clark desiccates a line 
across the hemorrhoid, similar to the primary scalpel incision in the usual 
technic. The needle is then inserted into the clot and the vein destroyed. 
The hemorrhoid is then incised, without hemorrhage, and the clot curetted 
out. 

Internal Hemorrhoids. —Occasionally a general anesthesia is em¬ 
ployed but usually thorough local anesthetization is sufficient. After the 
sphincter is sufficiently dilated each hemorrhoid is grasped by the forceps 
and clamped at its base in the direction of the muscle fibers, the needle is 
inserted and the growth destroyed. 

Fissures. —Fissures should be thoroughly desiccated, followed by 
curetting; the base .is then desiccated again. The infected membrane is 
thus thoroughly destroyed and the entire tract sterilized. Reinfection 
has not occurred in Clark’s cases. The advantage of this method of treat¬ 
ment is given by Clark as follows: There is slight postoperative discom¬ 
fort; danger of stenosis avoided because of the small amount of cicatrix 
formed, as the trauma of the tissues is very slight. Embolism is avoided 
because the dilated veins are completely destroyed and no chance is given 
for clotting. Secondary hemorrhage does not occur because the vessels are 
sealed for a short distance below the blades of the clamp. 


DISEASES OF THE RESPIRATORY SYSTEM 

Coryza. —Innumerable methods of attack have been used upon this 
common condition. In the congestive stage the combined use of several 
physical agencies has been pretty successful in treating this affection. 
We cover the eyes with a folded towel and expose the face to 1,500 candle- 
power radiant light as closely as the patient will tolerate, usually twelve 
to sixteen inches for fifteen minutes. This is followed by the use of the 
Oudin high-frequency current in each naris, by means of the nasal vacuum 
or non-vacuum electrode. The electrode is gently inserted and carried 


502 


COMBINED METHODS OF PHYSIOTHERAPY 


straight back as far as it will penetrate easily, before the current is turned 
on. The first rheostat and first spark gap usually give sufficient current. 
The electrode is pressed gently against the different parts of the walls of 
the nasal passage. The current should then be turned off, the electrode 
withdrawn and inserted into the other side. From five to eight minutes 
application of the current to each nostril is usually sufficient to dry off 
and shrink the membranes considerably. 

The quartz light is then applied from the water-cooled lamp through 
the nasal applicator inserted as deeply as possible, for a minute and a 
half, after which it is slowly withdrawn, during the next half minute. In 
throats open enough to allow for the procedure, the pharyngeal applicator 
may then he applied through the mouth to the nasopharynx, which is 
irradiated for two to three minutes. In the chronic stage of this condition, 
the treatment is much less efficient hut even then gives symptomatic re¬ 
lief. If the treatment has been instituted promptly in the acute stage 
it is usual for the disease to yield very quickly. 

Tonsillitis. —Three common types of tonsillar involvement in children 
have been described, associated usually with hypertrophy: the acutely 
inflamed, those with subacute and chronic inflammation and the simple 
enlarged tonsil. The first type should he removed surgically when pos¬ 
sible. The second type treated by combined X-ray and the application of 
ultraviolet light, and the third by X-ray or by surgical removal. In 
subacute inflammation the X-ray is applied by the Witherbee technic on 
alternate weeks. In applying the ultraviolet light, Pacini advises fre¬ 
quent short exposures of not over thirty seconds each, with the use of 
the special tonsillar applicator. This is a conical steel cylinder, with a 
quartz compression applicator fitted to its tip. He emphasizes the point 
that prolonged exposure tends to coagulate the protein of the mucosa 
which interferes with surface drainage. The spraying of the tonsils with 
a dilute solution of peroxid of hydrogen is sometimes advisable. 

In surface infections of the tonsil and infected crypts, Donnelly ad¬ 
vises the use of a localizing cylinder, beveled at the end to enclose the 
tonsil, which is exposed for from three to five minutes with the water- 
cooled lamp. Where for any reason ordinary tonsillectomy might be 
contra-indicated, as in hemophilia or in patients unable to take a general 
anesthetic, W. J. Harrison, of England, uses surgical diathermy. The 
surface of the tonsil is painted with iodin and it is then destroyed by 
electrocoagulation, using 300 to 500 milliamperes of current, William 
D. McFee, of Haverhill, has developed a technic for the removal of ton¬ 
sils by figuration with the monopolar high-frequency current. A special 
tonsil electrode is used, of wire imbedded in glass, terminating at the 
center of a hooded, bell-shaped end. This method requires from three 
to six applications, the slough coming away without hemorrhage, and it is 
very satisfactory when ordinary surgical enucleation is impossible. 


DISEASES OF THE RESPIRATORY SYSTEM 


503 


Diphtheria Carriers. —Donnelly reports forty cases of diphtheria 
carriers to whom ultraviolet light was applied to the tonsils and naso¬ 
pharynx by the use of the cylindrical localizer and water-cooled lamp. 
The first exposures were three to five minutes and, if succeeding cultures 
were not negative, repeated doses of from four to six minutes each were 
given. Fifty per cent of these cases were negative after the first exposure 
and never more than three exposures were required. Additional cultures 
should be taken several days later. 

In our series of five cases the ultraviolet light was applied from water- 
cooled lamp to the tonsils and throat by the tonsillar applicator for three 
minutes and to the posterior nares by the quartz nasal applicator for 
two minutes, including the slow gradual withdrawal of the applicator 
during the last half minute. Cultures were not taken in this group until 
after three exposures, when four were found negative and one doubtful 
which also became negative after the fourth exposure. Pacini follows the 
same technic with a shorter exposure, less than a minute, and adds the 
curved rod applicator, turned upward beyond the soft palate into the naso¬ 
pharynx. This last procedure is important in completing the irradia¬ 
tion of the entire surface most commonly infected. The middle ear and 
sinuses occasionally involved cannot be reached directly. So eminently 
satisfactory has been this treatment that it suggests similar results in 
carriers of the organisms of meningitis, pneumonia and influenza, both in 
the recuperative stage and as a preventive for those who have been 
definitely exposed. There can be no question that ultraviolet light is per¬ 
haps the least dangerous and most effective surface bactericide at our 
command. 

Tuberculous Laryngitis. —Blegrad reports fifty-two cases treated by 
body exposure to the carbon arc light. The initial exposure was fifteen 
minutes, increasing gradually to one hour in about a week’s time. On deep- 
seated local lesions he used the galvanocautery. The laryngeal symptoms 
were greatly improved in practically every case, although the associated 
pulmonary condition prevented complete cure in quite a large proportion 
of them. 

A comprehensive technic includes the local application of ultraviolet 
light from the water-cooled lamp through the laryngeal applicator for from 
one to two minutes, with slow, steady increase in exposure time, coupled 
with cross-firing the larynx by means of compression with the large sur¬ 
face applicator and body exposure, following the technic already outlined. 

Gas Laryngitis. —We have had many cases of gas laryngitis among the 
ex-service men. A combination of surface high-frequency and the internal 
and external application of quartz light, as just described, has brought good 
results in most cases. 

Simple catarrhal laryngitis may be treated in the same way, adding 
intensive radiant light externally for twenty minutes. 


504 


COMBINED METHODS OF PHYSIOTHERAPY 


Sinusitis. —There is no question that the sinuses connected with the 
respiratory tract can be penetrated by radiant light and, to some extent, 
by ultraviolet light, when properly applied. The effect is that of thinning 
and, to some extent, sterilizing the exudate, thus accelerating drainage. 
Local, intensive, high candle-power radiant light for twenty to thirty 
minutes is applied directly over the affected area as close to the patient 
as is tolerable. Ultraviolet light with compression from the water-cooled 
lamp is then used for one or two minutes. The patient should be fore¬ 
warned of the sunburn on the face which will follow this application. 
Marked relief of pain is usually the immediate result of the treatment. 
Ultraviolet light should be applied, where possible, through the nose, in 
addition to the surface application. 

Bronchitis. —The favorable effect of the common external counter- 
irritants is well known. The use of hot, heavy gummy substances smeared 
on the skin is still in vogue, in spite of their obvious disadvantages. The 
effects of these can be obtained much more efficiently by the use of high 
candle-power radiant light. 

In certain types of bronchitis, especially those associated with a 
tendency to asthma and simple croup, antispasmodics are indicated. Di¬ 
athermy will relieve this condition by the relaxing effect of the intense 
deep-seated heat produced. The sedative effect on the mucosa of the 
larger and smaller bronchi is more quickly secured than by the use of 
drugs. In cases where the expectoration is too profuse, diathermy should 
be used sparingly if at all. 

Radiant light, 1,000 to 1,500 candle-power at fifteen inches, is ap¬ 
plied; thirty minutes to the anterior and ten minutes each to the lateral 
and posterior surfaces of the chest. This is followed by direct diathermy 
with flexible metal plates large enough to cover the entire upper chest. 
The patient may lie on the posterior plate. The anterior electrode may 
be held gently on the chest by the patient, but preferably by a light 
sandbag or with adhesive plaster. Use 1,000 to 1,500 milliamperes of 
current, taking double the usual time to reach maximum and to reduce 
the current. 

Bronchopneumonia. —The effect of the application of radiant light is 
not as great in this condition as in inflammation of larger bronchi, while 
that of diathermy is still more striking. Radiant light, however, should 
be used where possible, applied to the anterior chest wall for twenty to 
thirty minutes. Diathermy is given by the technic just described. 

Lobar Pneumonia. —The group of cases in my consulting service, in 
the United States Marine Hospital No. 21, New York, is now large 
enough to justify certain definite conclusions as to the effect of diathermy 
in this condition. This disease varies so greatly in its mortality in dif¬ 
ferent seasonal epidemics and in the different types, that all conclusions 
as to the efficacy of any given treatment must be most guarded. In the 


DISEASES OF THE RESPIRATORY SYSTEM 


505 


literature, a few scattered cases of pneumonia treated by diathermy are 
recorded. The lack of laboratory reports and daily physical findings 
render difficult any judgment upon the efficiency of the methods used. The 
permission and assistance of the Medical Officer in Charge and the co¬ 
operation of the Ward Surgeons and Laboratory Staff made this study pos¬ 
sible. The only function of the department of physiotherapy was to give 
the treatments. A complete record of pulse, temperature and respiration 
together with daily chest findings was kept of every case by the Ward 
Surgeons, Dr. Trimmer and Dr. Boland, under the direction of Major 
Brvon and Major Ridlon, Chiefs of the Medical Service. The labora¬ 
tory findings were made by the chief of that service, Dr. Taylor, and a 
number of chest plates of particularly interesting cases were secured. 
Treatments were given by the head physiotherapy aides, Miss Cargill and 
Miss Randall. 

The apparatus used was a portable type of high-frequency machine 
capable of delivering up to 2,500 milliamperes of current. This and similar 
apparatus may be conveniently carried to the different wards of a hos¬ 
pital or to private homes and used wherever there is an alternating cur¬ 
rent. The technic was as follows. The patient was gently turned on 
his side and the flexible metal plates, about five by seven inches, covered 
with hot shaving soap lather, were placed directly over the affected lobes, 
anteriorly and posteriorly. The patient was then returned to his former 
position, lying directly upon the posterior electrode, the bedding being 
protected by a heavy folded towel. The anterior plate was held gently 
against the chest wall by the aide or nurse. In the first eighteen or nine¬ 
teen cases the maximum current of 2,000 milliamperes was used. The 
current was turned on very slowly, from four to five minutes being used 
to reach maximum and a further two or three in cutting it down, after 
twenty minutes at maximum. In the second group of cases, at present 
under treatment, the time has often been increased to thirty minutes and 
the maximum current reduced to 1,200 or 1,500 milliamperes with even 
better results. 

Dr. Wm. T. Boland, who was in immediate charge of practically every 
case, sums up the results of this work up to February 15, 1923 from the 
standpoint of the internist as follows: The 1922-1923 group of cases, 
largely Types I, II and III, did not respond quite as well as the first 
group, which were mostly of Type IV. With a single exception there was 
a slight fall in blood-pressure with a fall in pulse rate of from five to 
ten points following the treatments. The respiration rate was not greatly 
lessened, but breathing was much less labored. Free perspiration was 
induced. Following the diathermy treatment, each patient was able to 
sleep from one-half to three hours in a quiet, natural manner and the 
pains in the chest were lessened following each treatment in every case 
except one. 


506 


COMBINED METHODS OF PHYSIOTHERAPY 


The results obtained in treating lobar pneumonia with diathermy in¬ 
dicated that it might have an influence in hastening recovery, particularly 
in shortening the period of resolution. There is some evidence to indicate 
that pneumonia may be aborted by the early and intensive use of diathermy. 
This result has apparently been the case in a number of instances and 
yet it is extremely difficult to prove one way or the other. It seems 
logical, however, to employ it at the earliest possible moment after a 
diagnosis or provisional diagnosis is made, because of the almost absolute 
certainty that it is safe. The total duration of the active stage of the 
disease was apparently not affected in our cases, but the condition of the 
patient and the temperature findings were both markedly affected. The 
temperature started down by lysis immediately following the first applica¬ 
tion of diathermy, in nearly every case. A similar temperature effect 
was noted even in the few which had a lethal outcome. 

This statement can be made without fear of successful contradiction. 
A crisis does not occur in lobar pneumonia where diathermy is used. In 
fact, so striking is this point that in several of the scattered cases reported 
the diagnosis was placed in doubt because there was no crisis. In our 
cases the laboratory reports preclude any doubt as to the accuracy of the 
diagnosis. Still more marked, however, are the effects obtained on the 
patients’ symptoms in practically every treatment, the number of which 
is now several hundred. Cyanosis lessens or disappears; the expiratory 
grunt, when present, is markedly diminished, or it ceases entirely. The 
respiration rate usually falls and the breathing is less labored. The 
patient receives from two to four hours of distinct relief from distress 
during which he usually drops off to sleep. 

The question arises as to what actually occurs within the congested 
lung. This question is difficult to answer but we are certain that something 
definite occurs which relieves, at least temporarily, the overload upon 
the right side of the heart. Lymphatic and capillary drainage are un¬ 
doubtedly augmented and the intense heat produced, estimated at from 
twelve to twenty degrees Fahrenheit above that of the body, may me¬ 
chanically melt down some of the exudate. 

The relief felt by the patient after the crisis is, of course, out of 
proportion to any sudden physical change occurring within the lung itself 
and a somewhat similar and unexplainable relief occurs here. The body, 
at a great expenditure of energy, reacts to the toxins with a rise of from 
five to seven degrees of temperature, perhaps even greater than that 
within the congested lung. If the organic structure of heart and kidneys 
and sufficient pulmonary tissue remains intact and the dose of toxin is 
not overwhelming, crisis occurs and the patient is started on the road 
to recovery. By means of diathermy we create, without the rapid burn¬ 
ing of the body’s available energy, a more intense and sharply localized 
temperature. We do not, of course, aid directly in the formation of anti- 


DISEASES OF THE RESPIRATORY SYSTEM 


507 


bodies. The results which have been found clinically in the application 
of diathermy, therefore, closely parallel what might have been expected. 
The most careful and continuous observation of these cases has at no time 
demonstrated that diathermy was harmful in any stage or type of the 
disease. Further study will undoubtedly reveal the fact that this measure 
is more useful in certain stages of the disease than in others. It may even 
point to the fact that at times it is contra-indicated. Up to the present, 
however, this has not occurred. It has not prevented other lobes from 
being affected while one lobe was being treated. The few occasions when 
this occurred came, however, at a time when the diathermy treatments 
had been markedly reduced because of the improvement in the lobes under 
treatment. 

It is believed that the marked symptomatic relief which follows the 
application of diathermy is great enough to turn the scales in many severe 
cases. Shorter treatments at three to four-hour intervals during: the en- 
tire critical stage would be indicated in such conditions. The writer 
would urge a wider employment of diathermy in pneumonia. It has 
seemed to him to be a most hopeful type of treatment and should be 
coupled with the serum in those types of the disease in which serum is 
indicated. We may confidently expect that in the near future our knowl¬ 
edge of the results of this type of therapy will be greatly increased. 

Pulmonary Tuberculosis. —There has recently occurred some change 
in our conception of the manner in which certain physical agents play 
their part in the treatment of this condition. It has been the writer’s 
privilege to be associated in a consulting capacity with Major Leonard 
Woolsey Bacon, Surgical Chief, in the Physiotherapeutic Department of 
the Government Hospital for tuberculous ex-service men at Hew Haven 
for the past three years. He is indebted to Major Bacon for the exposi¬ 
tion of the theory upon which the therapeutic application of exercise and 
ultraviolet light to this disease is based. A brief statement of these Con¬ 
ceptions is necessary to an understanding of the treatment regime. 

The tubercle bacillus produces a toxin to which the body reacts and, 
as a result of which reaction, is enabled to build up a cicatricial fibrotic 
encapsulation of the bacilli. Within this fibrous wall the bacilli undergo 
slow attenuation in their virulence. Under conditions favorable to them 
they undergo development, dissolve or break through the protecting capsule 
and again become a menace. The allergenic responses of the tissues to 
the invasion of the tubercle bacillus is essential to its proper defense 
against the organism. In many cases there remains for considerable 
periods a state of fair balance, in which partly attenuated organisms are 
surrounded by a fair amount of protecting cicatrix, the general bodily 
health remaining below par. Such patients, while showing normal tem¬ 
perature at rest, may exhibit an overactive thyroid, liyperthyroidosis, re¬ 
current colds and typical effort syndrome. These are the patients who 


508 


COMBINED METHODS OF PHYSIOTHERAPY 


break down readily upon the attempt to resume normal activity. To 
protect such a patient properly, an increasing stimulation to the forma¬ 
tion of adequate cicatricial tissue around the tubercle is essential. This 
stimulus may be obtained by intentionally stirring up the dormant bacilli 
to increase toxin production. By rest, fresh air and adequate nutri¬ 
tion the body is prepared for these responses, and the bacilli are at the 
same time attenuated in their virulence. This is probably the immuno¬ 
logical action of tuberculin. A similar result may be obtained by what 
might be called the auto-inoculation method, using the effect of ex¬ 
ercises and ultraviolet light to attain a systemic reaction. In seeking to 
bring about this result an overdose may bring disaster. Clinically, this 
condition is met with in the too early return of the patient to motor 
activity or in excessive doses of heliotherapy or actinotherapy. Under the 
stimulation of an excessive dose of toxin the body attempts to reestablish 
its local defenses, but the areas involved are increased in both size and 
number and the protecting structure is necessarily weaker. Bacon sug¬ 
gests that the effect of exercise is due to changes in the fluids and con¬ 
sequent osmotic pressure, leading to increased absorption of toxins in 
the vicinity of the tubercles, scattered throughout the spongy tissue of 
the lungs. Both exercise and ultraviolet light, as will be later shown, 
produce concomitant effects, distinctly favorable to recuperation, if 
graded so as to invoke the optimum response. The emphasis here made 
is to show how their employment in the wrong stage of the disease or 
in excessive amounts may be extremely harmful. Therefore, these potent 
agencies must also be used with extreme care. In that stage of the dis¬ 
ease where the temperature has returned practically to normal and the 
active symptoms have been arrested by rest, adequate diet and fresh 
air, carefully graded treatment by exercises and ultraviolet light, is 
indicated. 

Exercises .—After the patient’s temperature has been practically nor¬ 
mal for some two to four w T eeks, the exercises in Group 1 may be given. 
Anything more than the slightest febrile reaction demands a further 
period of rest before again attempting exercise. If a few weeks employ¬ 
ment of these gentle exercises produces no untoward symptoms, the ex¬ 
ercises included in Group 2 may be substituted. Unfavorable responses 
to this exercise dosage place the patient back at rest, or in Group 1, 
according to the severity of the reaction. After four to twelve weeks 
of work with this group a patient may be advanced to Group 3, after 
which he is ready for discharge from the hospital or sanitarium and 
should be in condition slowly and gradually to resume his former occupa¬ 
tion. These Exercises may be entrusted to the well-trained physiotherapy 
aide or physical director, but must be under the constant observation of 
the physician, who should withdraw at once any patient showing signs of 
distress. 


DISEASES OF THE RESPIRATORY SYSTEM 


509 


Group 1 

These exercises constitute a series of slowly performed, gentle ex¬ 
ercises in which all strain on the chest wall and all vigorous breathing are 
avoided. They are slowly coordinated arm and leg exercises and very 
gentle trunk bendings which may be performed in recumbent, sitting or 
standing positions. From two to four repetitions of each joint movement 
are sufficient. Rest periods are very frequent during the ten to twenty 
minutes lesson. 

Group 2 

The patients taking these exercises are assembled in regular class 
formation. They are given the full number of general setting-up ex¬ 
ercises performed at a relatively slow rhythm. Slowly performed march¬ 
ing tactics are sometimes included. Three to six movements of each type 
are sufficient. Good form in the execution of the movements is striven 
for, hut without speed or snap. Rest periods are given during the half- 
hour period. 

Group 3 

These exercises constitute a general, snappily executed, full setting-up 
drill with the movements repeated four to eight times each with vigor 
and speed. Walking and light games may be included in this group. 
When the reaction to this form of exercise is favorable, the patients are 
ready for their discharge from the hospital or sanitarium and a return to 
their former occupation in fine muscular condition. 

In our government hospitals these exercises have the further advan¬ 
tage of demonstrating, both to the men and to the medical staff, the 
patients’ fitness for leave or discharge. 

Ultraviolet Light .—The following technic of applying ultraviolet light 
to patients whose condition was complicated with pulmonary tuberculosis 
has been in operation more than two years at the Government Tuber¬ 
culosis Hospital at Hew Haven and the results have proved eminently 
satisfactory. The same technic is applicable to patients suffering from 
uncomplicated tuberculosis. Major Bacon divides the body into eight 
zones, four on the anterior and four on the posterior aspect. The first 
zone extends on the anterior surface from the feet to the knees; the sec¬ 
ond includes the anterior thigh region and the dorsum of the hand and 
wrist; the third the abdomen and the anterior part of the forearm; the 
fourth the chest and neck. Zones V, VI, VII and VIII are corresponding 
areas on the posterior surface of the body. Irradiation with the 2,000 
candle-power light for ten minutes precedes all treatments. This is an 
essential part of the regime. 


510 


COMBINED METHODS OF PHYSIOTHERAPY 


Treatment 1 

With the air-cooled mercury-tungsten lamp at a distance of thirty 
inches, Zone I is exposed for one minute. 

Treatment 2 

Zone I is exposed for one minute, Zones I and II for an additional 
minute. The treatments progress in this manner until all zones have 
been exposed, with a total time of thirty-six minutes. After sixteen treat¬ 
ments the series has been completed and the lamp is lowered two inches, 
then the whole anterior surface of the body is treated for two minutes. 
The next day the posterior surface is rayed for the same length of time. 
This procedure is repeated until the lamp has been lowered to twenty 
inches, after which the zone method is again resorted to, increasing two 
zones at a time, instead of one, to a maximum of thirty-six minutes. This 
very gradual increase has enabled our working up to maximum in nearly 
every case without producing increased febrile symptoms. 

Hydrotherapy .—The late Simon Baruch, in his text on hydrotherapy, 
calls attention to the stimulative effect of cool and cold water applied to 
the skin in pulmonary cases. The water is first applied at a temperature 
of about 90° E. and given at a slightly lower temperature in each suc¬ 
ceeding treatment, as the patient becomes used to it. It may be applied 
as a sponge bath or by means of the fan douche and should never be given 
at a lower temperature than 70° F. A distinct gain in appetite, sleep and 
weight is claimed for this method of treatment. It would seem to be 
indicated in that stage of the condition in which active exercise has been 
advised and should be carefully watched for the appearance of unfavorable 
symptoms in exactly the same way as has been advised when exercise was 
given. 

Massage .—In the beginning of the quiescent period, at that stage in 
which restricted use of general mild exercise was advised, general mas¬ 
sage, consisting of mild petrissage and effleurage, may be employed with 
advantage to the patient. 

In a light general treatment or where the four extremities only are 
included, only about one-third of the time should be employed as in the 
average general massage treatment. 

In the terminal stages of the disease, no procedure brings more com¬ 
fort to the patient than gentle general massage. It is possible to improve 
local circulation impeded by pressure and immobility and to prevent or 
delay the appearance of bed sores. 

Pleuritis.—The pain incident to the acute inflammation of the pleura 
can be relieved by local intensive radiant light and surface high-frequency 
or direct diathermy. The 1,500 candle-power lamp at a distance of fif- 


DISEASES OF THE RESPIRATORY SYSTEM 511 

teen to eighteen inches for thirty minutes will produce a marked analgesic 
effect. 

Diathermy should be applied by large flexible metal plates, so ar¬ 
ranged as to be only four or five inches apart on the affected side of the 
chest. In this position, beside the through and through heat, a distinct 
edge effect is produced. The current will flow in greater density through 
the subcutaneous tissue between the plates and heat may be produced to 
tolerance. Use 1,000 milliamperes for thirty minutes. 

With simple effusion the same technic is continued to promote drainage. 

Empyema.—This complication requires surgical drainage. With drain¬ 
age established and even the institution of the Carrel-Dakin technic, all 
cases do not progress favorably. It was in this type of case, often fur¬ 
ther complicated with osteomyelitis of the resected rib stumps, that physio¬ 
therapy attained some of its most brilliant results in the many post- 
influenza cases of this type which occurred in the Army. The treat¬ 
ment, as given, does not interfere in the slightest degree with the proper 
surgical procedures, including the Carrel-Dakin tubes. 

Major C. M. Sampson and Captain A. B. Hirsh treated a very large 
group of empyema cases at Fox Hills General Hospital, later the Hoff 
General Hospital of the Army. These were largely due to infection by 
the Streptococcus hemolyticus, many of the sequelae of the influenza- 
pneumonia remaining. 

The object of the treatment is to increase the local arterial blood 
supply, and both the quality and quantity of the phagocytes. Radiant 
light used alone did not produce a marked effect. When combined with 
direct diathermy, however, the results were very satisfactory. The first 
case treated had become steadily worse, after nine rib resections, and had 
thirteen discharging sinuses. 

Radiant light, from a 1,500 candle-power lamp for fifteen minutes, 
was followed by direct diathermy, applied right over the scars and dis¬ 
charging sinuses. At first, 300 milliamperes of current were used, 
gradually working up to 2,000 milliamperes for one hour. General ir¬ 
radiation with the air-cooled ultraviolet lamp was used, with increasing 
time starting at twenty-four inches for two minutes. This case was en¬ 
tirely healed in a comparatively short time. 

Nagelschmidt, Howaschick and Saberton have all attained equally good 
results in the application of diathermy to empyema. It is clearly in¬ 
dicated in all forms of pleuritis. 

Adhesions.— Cumberbatch has had results in treating these cases with 
chlorin ionization. The writer employed in his army cases a combina¬ 
tion of diathermy by the technic described above, and deep-breathing 
exercises. 

These graded deep-breathing exercises should be begun early, while 
the patient is still a bed case. They promote drainage and prevent the 


512 


COMBINED METHODS OF PHYSIOTHERAPY 


formation of adhesions. Once formed, adhesions may be stretched and 
broken np by their use. Slow, deep respirations of the “pectoral type” 
are given, with prolonged rest periods. They may, with advantage, be 
associated with bilateral arm abductions, where possible. 


DISEASES AND INJURIES OF THE SKIN 

The use of radium, X-ray and ultraviolet light in the treatment of 
various pathological conditions of the skin is a recent and rapidly spread¬ 
ing development in therapeutics. The relative value of each of these 
measures has not been definitely determined in every instance. The 
proper selection of the treatment cannot be standardized until the derma¬ 
tologists have thoroughly tried out all of these measures in cases where 
their application seems to be indicated. Broadly speaking, this general 
statement holds true. These physical agents are somewhat similar in 
action, as would be expected from the fact that they are derived from 
adjoining wave-lengths of light vibration. In most dermatological condi¬ 
tions amenable to treatment by both X-ray and ultraviolet light, the X-ray 
is usually quicker in its action but has a greater tendency to scar the skin 
and, except under most careful technic, has certain elements of danger 
not involved in the use of ultraviolet rays. In general and diffused con¬ 
ditions, like acne of the face, where temporary exfoliation by ultraviolet 
light might be disadvantageous, the X-ray is to be preferred. In most 
sharply localized conditions, the absolute safety of ultraviolet light is a 
point highly in favor of its use. 

Alopecia. —The general falling out of hair m early adult life yields, 
as a rule, most satisfactorily to the proper application of physiotherapy. 
Bernstein uses the air-cooled all-mercury burner at twenty-four inches for 
ten minutes, increasing five minutes per day to a maximum of thirty 
minutes. He treats the parts every other day for three treatments and 
then twice a week. Wise uses approximately the same technic with the 
treatments two weeks apart, and calls attention to the necessity of re¬ 
moving the scales if seborrheic eczema is present. One should reduce 
the time by half in using the tungsten-mercury air-cooled burner. It is 
better to move the patient’s head or the lamp slightly, during the treatment, 
so that the hair shadows will not prevent the light from reaching all parts 
of the scalp. 

We have found a combined technic to be still more efficient. Preced¬ 
ing the ultraviolet irradiation at the time, distance and daily increment 
mentioned, we use about eight minutes local application of the surface 
non-vacuum high-frequency scalp electrode which is made in the form of 
a coarse comb. The ordinary small surface electrode, however, may be 
used instead of this special one. A flexible metal electrode may be ap- 


DISEASES AND INJURIES OF THE SKIN 


513 


plied, to the wrist of the operator or patient and a finger-tip massage of 
the scalp which localizes the high-frequency stimulation may then he given. 
This may be substituted for the application of the high-frequency electrode 
directly to the scalp. 

It will be noted in many of these cases that the scalp is quite tight 
and the local circulation thereby somewhat impeded. With the palms 
placed over the forehead and occiput, then on both temporal, and finally 
on both parietal, regions, it may be loosened somewhat by circular knead¬ 
ing, moving the whole scalp on the skull. It is quite usual for the hair 
to stop falling out and for the itching, which generally accompanies this 
condition, to be entirely eradicated at the first treatment. 

Treatment should be four times a week for four to twelve weeks to ac¬ 
complish lasting and satisfactory results. 

Alopecia Areata. —In this condition the etiology will to a large extent 
determine the success of the treatment. Certain types are amenable to 
treatment by the technic just given above. 

Acne. —In severe cases of acne it is necessary to secure an exfoliation 
of the skin to produce a lasting result and the patient should be par¬ 
ticularly warned in regard to this, especially in the treatment of the face. 
The few days of disfiguration are rendered well worth while by the re¬ 
sults obtained in most cases. Fortunately the face responds particularly 
well to a thorough treatment. Certain writers, among them Clark, give 
an initial dose at twelve inches for ten minutes producing a sudden and 
sharp reaction. Bernstein uses an initial time of five minutes, distance 
thirty-six inches, adding five minutes and decreasing the distance six 
inches at each subsequent treatment, to maximum of twenty minutes at 
twelve inches. He gives one treatment every other day until three have 
been given, then twice a week if further treatments are necessary. 

Oliver points out the efficiency of ultraviolet light in acne vulgaris 
which may be given by the technic mentioned above, or with compression 
by the surface applicator from the water-cooled light three to five minutes. 

Pitcher states that the X-ray acts more quickly but with greater li¬ 
ability to the formation of scars and telangiectases. 

Angioma.— This condition may be treated with the water-cooled lamp 
surface applicator, with compression from twenty to forty minutes re¬ 
peated every three weeks. Lewis Jones, Guillemot and G. Betton Massey 
treat this condition by electrolysis. This may be done by the bipolar 
method with both needles in the tumor, or by using a single needle and 
the indifferent electrode placed elsewhere. Jones’ work at St. Bartholo¬ 
mew’s Hospital, in London, has been very successful, and he advises the 
earliest possible treatment of this condition because of its rapid growth 
in infants. The object is to coagulate the blood in the tumor and destroy 
the walls of the dilated vessel, obliterating the cavity while not destroy¬ 
ing the overlying skin. The positive pole needle must be platinum and 


514 


COMBINED METHODS OF PHYSIOTHERAPY 


the negative may he steel. They should be insulated with hard rubber 
or shellac so that they may pass through the healthy skin without 
destroying it. From twenty to forty minutes of current is used, accord¬ 
ing to the size of the growth. Large growths require multiple needles. In 
growths less than two centimeters in size, a single positive needle should 
he used with the negative electrode placed at a distance. General an¬ 
esthesia is sometimes necessary. The time necessary to destroy the walls 
of the vessel is from three to five minutes. Rarely more than two appli¬ 
cations are necessary. William L. Clark, of Philadelphia, uses desicca¬ 
tion with high-frequency current with good results. His technic is that 
attributed to him and described under Desiccation. He states that radium, 
however, is a method of choice in very large growths. 

Burns.— First-degree burns from any cause may he treated by pro¬ 
longed radiation at about thirty inches by the radiant light. Second and 
third-degree burns present a number of problems. The best surgical 
opinion seems to be leaning toward the conception that these injuries 
should always be considered as infected wounds. Sealing them in with 
some type of paraffin preparation occasionally gives brilliant results and 
does greatly allay the pain, hut it is not always a safe procedure. 

Any method which will arrest the pain, dry up the exposed area, 
sterilize and at the same time markedly stimulate the new growth of skin 
cells may be considered an ideal procedure. This ideal combination we 
have at hand in the ultraviolet light. Those who have employed it speak 
most highly of the results they have obtained with it. The air-cooled lamp 
should be used, with the all-mercury burner; the initial distance is twenty 
inches and the time three minutes, with one minute increment of daily 
treatments. With the mercury-tungsten burner, the initial time is one 
minute and a half, with one-half minute daily increment. Between treat¬ 
ments, dressings of sterile, dry gauze, not thick enough to be impervious 
to the air, are desirable. 

Where skin grafting is necessary, the ultraviolet light should he early 
employed as an aid. In fact, it is certain that the wider use of the ultra¬ 
violet light will decrease the indications for skin grafting. In deeper 
bums, involving tendon sheaths and other subcutaneous structures, long- 
continued use of ultraviolet light with the same technic as above given 
will greatly toughen and thicken the layer of new skin formed. Mas¬ 
sage, particularly friction and vibration, and radiant light will loosen 
adhesions and promote increased vascularity. X-ray and radium burns 
should always be treated with ultraviolet light by the same technic. I 
have seen, especially in X-ray hums, the most astonishing results in a 
number of army cases where skin grafting had been thought necessary 
and was finally not employed. 

Boils.—Wise states that no other remedy is as capable of relieving pain 
and skin tension as rapidly as ultraviolet light in furunculosis. Bern- 


DISEASES AND INJURIES OF THE SKIN 515 

stein uses the air-cooled lamp ten to fifteen minutes at twelve inches, care¬ 
fully covering the surrounding tissue. The greater bactericidal prop¬ 
erty of the water-cooled lamp would indicate its use, with firm gentle 
compression from the quartz surface applicator. The length of the treat¬ 
ment may extend from five to twenty or even thirty minutes with no ill ef¬ 
fect. Surrounding areas should be carefully protected with adhesive 
plaster or other covering. 

Our own recent series covers about seventy-five cases. Those cases 
appearing for treatment before the central softening had occurred were 
aborted, almost without exception, by a single exposure to quartz light. 
About four-fifths of the total number of cases in our series is included 
in this group. More advanced conditions should be incised and surgically 
cleaned. Our technic consists of the application, as close as is tolerable, 
of the 1,500 candle-power light for ten to twenty minutes followed by the 
water-cooled ultraviolet light through a localizer, or with compression, if 
possible, for five to ten minutes, after which a drain is inserted, accord¬ 
ing to the routine surgical procedure. This technic is repeated daily after 
the old drain has been removed and the boil cleaned. The period of 
sterilization and filling in with new tissue to complete healing is invariably 
reduced from 50 to 75 per cent by this combined technic. It is an ideal 
illustration of the correlation of surgical and physiotherapeutic procedure. 

Carbuncles.— These are treated by exactly the same technic and with 
the same indications as regards incision and drainage. This condition, 
too, in the early stage is frequently aborted. Both with carbuncles and 
boils, extreme induration is often present in the surrounding tissue. This 
stasis impedes the proper vascularity of the part and is usually one of 
the causes of the excessive pain common in these conditions. The in¬ 
duration may be greatly diminished by the use of the static effluve. 
Mechanical removal of the surrounding induration should be followed by 
an effort to increase the active blood supply to the part. As has been 
repeatedly mentioned, this can be done in no way so well as by diathermy. 
We find in this condition a special use for the “edge effect” of heat con¬ 
centration in the skin and subcutaneous tissue between two closely placed 
electrodes. Flexible metal plates are, therefore, selected, containing from 
three to six square inches, prepared as usual and applied opposite each 
other a short distance from the infected tissue. A small amount of cur¬ 
rent, from 300 to 600 milliamperes, is used. The relief from pain is 
often almost immediate and the acceleration of the healing process is, 
as a rule, visibly hastened. 

Callosities. —These conditions should be softened by prolonged soaking, 
and by the application of the ordinary com mixtures. This may also be 
accomplished by sodium chlorid ionization, using 2 to 4 per cent salt 
solution on the negative pole applied directly to the callus, giving 8 to 
10 milliamperes of current for thirty to fifty minutes. If not then re- 


516 COMBINED METHODS OF PHYSIOTHERAPY 

movable en masse the callus should be shaved or scraped to as great a 
degree as possible without causing bleeding. It may then again be 
ionized after the technic just described or treated with the large quartz 
surface applicator from the air or water-cooled ultraviolet lamp, using 
twenty to thirty minutes with firm compression. Recurrences can, as a 
rule, only be prevented by a proper redistribution of pressure or weight 
which was the original cause of the callus formation. 

Eczema. —Eczema being a group of conditions rather than a single 
entity, results vary widely in the different types. As has been mentioned 
before, rather mild doses of general ultraviolet light have brought on a 
form of eczema in several arthritic cases. When ultraviolet light is em* 
ployed, particularly in local eczematous conditions, it should be given in¬ 
tensively. Large areas may be treated by means of the air-cooled light, 
with initial exposure of five minutes at thirty-six inches, decreasing the 
distance five inches and increasing the time five minutes daily to a maxi¬ 
mum of twenty minutes at twelve inches. This is the technic of Bern¬ 
stein. We have found, especially in our chronic cases with thick ex¬ 
coriated skin, that it is better to give a massive dose at once, trying to 
obtain a complete peeling of the epidermis following the initial treatment. 
From three to ten minutes at twelves inches with the air-cooled lamp will 
usually accomplish the desired result. With the formation of new skin, 
the itching has generally entirely disappeared. In many cases it is ex¬ 
tremely difficult to obtain an even application of the light. Skin and 
mucous membrane folds must be carefully obliterated and all parts of 
the surface to be treated should be, as far as possible, equally distant from 
the burner. 

Epithelioma. —The squamous cell type of epithelioma may at times 
be destroyed by intensive doses of ultraviolet light. It yields, however, 
so much more readily to the separate or combined application of X-ray 
and radium that the use of quartz light is hardly justifiable. Metastatic 
extension of this and other malignancies often require intensive exposures 
to the X-ray which border on a destructive skin dose. There seems to 
be no question that a regime of ultraviolet light, especially in those who 
tan, will protect the skin somewhat from X-ray burn. Just how far this 
protection extends, and to what degree it will enable us to multiply the 
X-ray dosage, has not been worked out definitely. 

In advanced epitheliomas, with sloughing and offensive discharge, the 
ultraviolet light is most useful in minimizing these distressing symptoms. 
There are many cases beyond surgical aid where intensive doses of the 
light will clean the field to a degree unapproached by practically any other 
means at our command. 

Erysipelas. —A surprising amount of effect upon this condition has 
been attained by such a simple procedure as the application of radiant 
light. This measure should be applied to tolerance for several hours if 


DISEASES AND INJUBIES OF THE SKIN 


517 


possible. The use of ultraviolet light has been successfully employed by 
several writers. The technic as given by them is practically the same: 
initial distance thirty-six inches, time five minutes, lowering the lamp a 
few inches daily to eighteen inches and increasing the time to a maximum 
of five to fifteen minutes daily. Treatments should be given on alternate 
days. It is difficult to see why, with the surrounding area properly pro¬ 
tected, a destructive skin dose of ultraviolet, ten to fifteen inches for 
ten to fifteen minutes, depending upon the type of lamp used, should not 
at once be given. 

Erythema Induratum. —Oliver reports a number of cases successfully 
treated by the water-cooled ultraviolet lamp. He carefully protects the 
healthy surrounding skin and uses compression from one to two minutes 
directly over the affected area. 

Leukoderma. —Toomey secured, by means of the air-cooled light, a 
complete pigmentation in some of the affected areas of the skin and he 
was able to obtain some degree of pigmentation in all areas treated. This 
new pigmentation persisted for months, with no appreciable fading. For¬ 
tunately, the results secured in the treatment of areas on the face were 
the most satisfactory of any part of the body. In areas of the body 
normally covered by clothing, only partial pigmentation may be secured. 

Lupus. —In the erythematous type Clark secured good results in twelve 
cases of this condition, using ultraviolet light with compression for 
thirty-five minutes. 

Clark’s group of cases of lupus vulgaris were cleared up by not more 
than three exposures. He employed the same technic as in the erythe¬ 
matous type. Finsen has secured good results with the use of the carbon 

arc lamp. 

Nevi. —The flat type of nevi yield quite readily to intensive doses 
of ultraviolet light with firm compression. It is necessary to secure a 
good bum and blistering to obtain a satisfactory result. As much as 50 per 
cent improvement often follows a single application. Clark, Bernstein 
and Oliver employ a practically identical technic. The surface quartz 
applicator with the water-cooled light and heavy compression is used from 
twenty to forty minutes, repeated every three weeks as long as it is 
necessary. Prevost treats the former type by surgical ionization with the 
galvanic current, employing 5 milliamperes and using a technic similar 
to that described for the destruction of angioma. 

Psoriasis. —The treatment of this condition gives quite varied results 
and the general tendency is to a recurrence. Using the air-cooled quartz 
lamp, Bernstein and others start with an initial distance of thirty-six 
inches, which is reduced gradually to twelve, and an initial time of ten 
minutes, increased gradually to thirty. With the surrounding areas pro¬ 
tected, there can be no objection to the more prolonged initial exposure 
used by Wise and Oliver, who employ, from the start, the maximum dose 


518 


COMBINED METHODS OF PHYSIOTHERAPY 


of Bernstein’s technic. Treatments may be given every other day with 
the former and once a week with the latter technic. 

Pruritus. —This chronic condition is very common and very resistant 
to all types of treatment. As is well known, the palliative ointments to 
which most patients turn for relief tend, in the long run, to aggravate 
the condition. Underlying constitutional causes must be considered and 
where possible removed. There are many cases in which autogenous vac¬ 
cines and local applications of all sorts bring no relief. Radium and 
X-ray are often useful, but are not always free from danger. Ultraviolet 
light has definitely and rather permanently relieved a good many of 
these conditions. Quartz surface applications with compression from the 
water-cooled lamp are to he preferred in those locations in which it is 
possible to use them. Folds of skin and mucous membrane must be flat¬ 
tened out so that the compression and irradiation will reach all portions 
of the affected area in equal concentration. A destructive dose of two to 
four minutes is indicated. 

In pruritus senilis, Prevost has secured results by the application of 
static brush and high-frequency effluve in conjunction with the X-ray. 
Rolfe reports very satisfactory results in thirty uncomplicated cases of 
pruritus ani of from eight months to thirty-five years’ standing. From 
twelve to fifteen treatments were required by his method of zinc chlorid 
and iodin ionization which relieved at once the intensity of the symptoms. 
An almost complete relief from the itching persists for one or two days 
immediately following the treatment, and the return is less intense each 
time. During the course of the treatments no local applications are used, 
but local cleanliness is insisted upon. Rolfe employs a 2 per cent zinc 
chlorid solution. The ordinary galvanic plates are used, except that the 
active circular electrode is provided with a flexible metal back which can 
be bent and carefully shaped to the contour of the part to be treated. The 
patient is placed in the right Sims position with the indifferent elec¬ 
trode under the right buttocks. In moist macerated conditions of the 
skin, the zinc chlorid applied by the positive pole is used for two or three 
treatments, following which iodin is employed. He uses Lugol’s solu¬ 
tion diluted with four parts of distilled water at first; later less dilute 
solutions may he applied. The iodin is applied from the negative pole 
as the active electrode. Cotton may he soaked in the solution and directly 
applied to the part with the active pad placed over it. A rather long 
treatment, from thirty to forty minutes, is indicated, using only 2 or 3 
milliamperes of current. Treatments may be given daily at first, then 
twice a week. Rolfe rightly emphasizes the value of continued treatment 
at weekly intervals, for a short time after the disappearance of the 
symptoms. 

Tinea. —This condition will often yield to intensive doses of ultra¬ 
violet light. Air-cooled or water-cooled irradiations may he given at three 


DISEASES OF THE GENITO-URINARY SYSTEM 519 


to six inches distance for three to ten minutes, repeated every third day 
as long as is necessary. 

Telangiectasis. —This is best treated by the water-cooled ultraviolet 
light using surface application with compression. It may be given from 
ten to thirty minutes and repeated every ten days or two weeks, if nec¬ 
essary. 

Ulcers. —Ordinary varicose ulcers will heal, as a rule, more rapidly 
under the application of ultraviolet light than by the usual routine sur¬ 
gical procedures. An air-cooled light is to be preferred to the water- 
cooled, except where there is much infection, when the use of the latter 
is indicated. Stowell emphasizes the value of preliminary surgical 
cleansing and the use of static sparks and effluve to reduce the induration 
of surrounding tissue when present. This will greatly assist in relieving 
the lymphatic stasis and reinstituting the normal blood supply. The leg 
should be kept elevated during the entire treatment, and after the treat¬ 
ment should be bandaged firmly and evenly from the toes up while still 
elevated. 

The ultraviolet light should be applied in stimulative doses, the initial 
one being from four to five minutes at thirty inches, with a reduction of 
distance to eighteen inches and an increase in the time to a maximum of 
twenty minutes. The treatments should be given every second or third 
day. Wise reports prompt healing in many cases so treated and Oliver 
speaks of almost uniformly good results in twenty-five of his cases which 
were healed with a good, thick, new epithelium. Oliver exposes the skin 
for about an inch around the ulcer and uses two minutes at ten inches 
once a week. In my cases I have, employed radiant light for ten minutes 
followed by the ultraviolet light and have used massage as an aid in the 
removal of the commonly associated lymphatic stasis. 

Ulcers of the pressure variety following the removal of casts or the 
ordinary decubital type are treated by stimulating massage of the sur¬ 
rounding tissues, the removal of lymphatic stasis by static or massage, 
and by the direct application of radiant light and ultraviolet light with 
a similar technic to that just given. 


DISEASES OF THE GENITO URINARY SYSTEM 

Amenorrhea. —Cases where operative procedures are not indicated 
may be treated by physiotherapy. 

This condition when associated with neurasthenia and low blood-pres¬ 
sure is amenable to treatment by static charge from the negative pole. 
Where anemia is pronounced a course of general actinotherapy should be 
given. Turrell has secured good results by the use of diathermy. Eight 
to twelve hundred milliamperes should be given for thirty to forty min- 


520 


COMBINED METHODS OF PHYSIOTHERAPY 


utes with one electrode on the lumbar region and the other applied over 
the ovaries. The plates should be about five by eight inches. The treat¬ 
ment is begun a week before the expected period and continued daily 
until menstruation begins. 

Dysmenorrhea. —Lewis Jones and Cumberbatch advise the employ¬ 
ment of static charge with effiuve to the lumbar spine beginning a week 
or ten days before the period and discontinuing the treatment at its onset. 

Turrell has secured results with direct diathermy, using a large in¬ 
different electrode over the lower back and a smaller active electrode over 
each ovarian region in turn, 2,000 milliamperes for ten minutes in each 
region. Treatment should be instituted three days before, and may be 
given during the period, if the pain is severe. 

Exercise. —Mosher, Drew and the writer have repeatedly emphasized 
the fact that women must be taught to regard menstruation as a perfectly 
normal function and not as an illness. The value of light exercise during 
the entire period in the absence of real pathology has been proved. 

Many cases are due in part to faulty posture, improper clothing, con¬ 
stipation and other conditions which must receive attention. Warm bath¬ 
ing is not only safe but advisable. 

Walking, class-room exercises, light floor work and tactics should be 
given without interruption. Violent athletics should generally be inter¬ 
dicted for two or three days. 

Special exercises should be given to all severe cases. The effect of 
this exercise treatment in a large group of college women, reported by 
Clelia Mosher of Leland Stanford University, has been to shorten the 
total length of the period, diminish the pain and improve the mental at¬ 
titude of the patients. 

The patient is placed in the supine lying position, knees flexed. One 
hand without pressure or a small book is then placed on the abdomen. 
The patient’s attention is directed to the raising and lowering of the 
abdominal wall to the greatest possible degree without straining, by slow, 
deep respiratory movements. Thus the diaphragm is used as a suction 
pump to deplete pelvic congestion. Five to ten repetitions of the ex¬ 
ercise are advised morning and night every day including the menstrual 
period. 

Endometritis. —Few conditions are more satisfactorily treated than 
this one by eleetrotherapeutic measures. Except in the presence of placen¬ 
tal tags, ionization has every advantage over curettage in the treatment of 
endometritis. It is more safe and less inconvenient, requiring no special 
preparation, hospitalization or loss of time. Every part of the endometrum 
is reached, every crypt of the mucous membrane is penetrated. 

W. J. Turrell emphasizes the necessity for employing a correct technic. 
He surrounds the patient’s lower abdomen with a bath towel wet with 
saline and binds on the metal pad completely around the body over the 


DISEASES OF THE GENITO-UEINARY SYSTEM 521 


towel. The metal pad is then connected to the negative pole of the 
galvanic machine. Zinc or copper sounds may he used as the positive 
pole. The former are chosen when the septic discharge is pronounced 
and the latter in cases where there is much bleeding. The sound selected 
is insulated in its vaginal portion by rubber tubing. Turrell treats cervical 
erosions at the same time by wrapping a piece of absorbent cotton soaked 
in a 2 per cent zinc sulphate solution around the sound and applying it 
to the os. The patient is placed in the Sims position, the sound care¬ 
fully introduced and the current turned on very gradually. Twenty to 
thirty milliamperes of current are used for fifteen minutes. If pain 
occurs the current should at once be reduced. Cases which develop severe 
ovarian or tubal pain during treatment should be referred to the sur¬ 
geon at once for a thorough reexamination. If any difficulty is en¬ 
countered in the removal of the sound, Cumberbatch has suggested revers¬ 
ing the current for a short period of low intensity. This will permit easy 
withdrawal. He and Sloan use a glass speculum. 

Cervical Erosions. —The technic of treating this condition by zinc 
ionization with the galvanic current has just been described in the treat¬ 
ment of endometritis. 

The perfection of the quartz speculum now permits the application 
of ultraviolet light directly to the cervical lesion. One or two minutes in 
direct apposition should be given from the water-cooled lamp, with slight 
daily increase in the time of the exposure. 

Improved circulation may be secured by the application directly to 
the cervix of the high-frequency vaginal electrode. By the use of this 
internal electrode and a surface plate electrode, about six by eight inches 
in size, a direct diathermic current may be given which will greatly hasten 
the healing of old lesions. Eight to twelve hundred milliamperes are 
used for twenty minutes. The surface plate may be applied to the lower 
abdomen and lumbar spine at alternate treatments. 

Infantile Uterus. —Professor B. C. Hirst, of the University of Penn¬ 
sylvania, has described a technic which has been very successful in the 
development and restoration to function of the infantile type of uterus. It 
is usually preceded by cervical dilatation and a course of corpus luteum 
and pituitary extract, which alone often give no results. He based his 
work on the theory that the uterine muscle can be developed by elec¬ 
trical stimulation as can any other atrophied or poorly developed muscle. 
His technic is as follows: 

A copper electrode is inserted into the uterine cavity with the neces¬ 
sary aseptic precautions. A large sponge electrode is placed over the ab¬ 
domen; the patient is then given galvanism with the negative pole in 
the uterus, 9 to 12 milliamperes. This is followed by rapid and slow 
faradism; finally by the sinusoidal current, the treatment continuing for 
twenty minutes and being applied every other day; intermitted in case 


522 


COMBINED METHODS OF PHYSIOTHERAPY 


the menstruation occurs, but otherwise continued for about three months. 
Results are not secured by less than six weeks’ treatment. No infec¬ 
tion of the endometrium or of the appendages follows this treatment, but 
naturally the greatest care in aseptic technic is necessary. The use of both 
faradic and sinusoidal is probably unnecessary. 

In case the cervical canal is too narrow to admit one of the copper- 
tipped electrodes made for intra-uterine use, a narrow, flexible platinum 
electrode is employed which is practically indestructible. Another re¬ 
sult of this treatment is the permanent enlargement of the cervical canal 
by electrolysis so that the dysmenorrhea, which is an almost constant ac¬ 
companiment of the lack of physical development, is usually permanently 
cured. 

G. Betton Massey employs a similar technic, giving the intra-uterine 
treatments but once a week. He points out the contra-indication for this 
technic in inflammatory conditions of the tubes. 

It would seem here, too, that the selection of either the faradic or the 
sinusoidal current should suffice, if combined with the constant current. 

Pelvic Inflammatory Conditions. —Sperling obtained 56 per cent of 
subjective cures and 43 per cent of relief of symptoms in a variety of 
these conditions in one hundred and ten cases. He used direct diathermy. 
Continued treatment was required in some cases. 

The greatest care must be exercised to exclude cases in need of sur¬ 
gical intervention; on the other hand, much may often be accomplished 
in many cases unrelieved by palliative procedures. 

Great relief often follows prolonged radiant light of high candle-power 
followed by gentle, long-continued diathermy, which may be given by 
means of anterior and posterior surface plates or by alternating them and 
using the vacuum or non-vacuum vaginal electrode as the other pole. 
Thirty to forty minutes’ use of a current of 600 to 1,200 milliamperes is 
indicated. 

Many cases of low-grade chronic inflammatory conditions are associ¬ 
ated with a persistant chronic passive congestion of the entire adnexa. 
These patients do not take the general exercise which increases the re¬ 
spiratory excursions of the diaphragm and tends mechanically to relieve 
this congestion. There should, therefore, be given in association with the 
radiant light and diathermy, gentle deep respiratory exercises of the ab¬ 
dominal type, two or three times daily. The patient should be in the 
dorsal recumbent position with knees raised and take five to fifteen deep 
respirations. 

As soon as local tenderness and pain are relieved the patient should be 
encouraged to take light exercise of a general type. Cases complicated 
by chronic constipation may, as soon as the cessation of local tenderness 
permits, begin the series of abdominal exercises outlined in the treatment 
of that condition. 


DISEASES OF THE GENITO-URINARY SYSTEM 523 


Enuresis. —A toning up of sphincteric muscle and nerve control 
sufficient to abate this condition has often been accomplished by electrical 
stimulation. 

Turrell employs a coarse wire faradic current, applied to tolerance, 
by electrodes placed on the perineum and lumbar region for ten minutes. 

In adults the application of the static induced current from the nega¬ 
tive side of the static machine, by means of a rectal electrode, has given 
good results in a number of cases. A slow surging current is used for 
ten to fifteen minutes. 

Gonorrhea. —In the female this disease is often extremely resistant to 
treatment. Kyaw has found the organisms to be killed in six hours at a 
temperature of 40° C.; in three hours at 42° C. and in one hour at 44° C. 
His patients withstood a temperature under diathermy of 44.5° C. for 
hours without harm. He used one vaginal and one surface electrode for 
three hours, at times extending the time to nine hours with three hours’ 
intermission. The temperature may be checked by thermometers in vagina 
or rectum. Ho other writer employs such lengthy treatments or speaks 
as certainly of obtaining a cure. 

Yon Biiben reports a number of cures by the use of diathermy in cases 
which were resistant to other methods. 

Zinc or copper ionization by the technic described for endometritis has 
been used with success by Cumberbatch and others. 

The combination of Kyaw’s intensive diathermy regime, with direct 
irradiation by ultraviolet light from the water-cooled lamp by means of 
the quartz speculum, should prove an efficient means of treatment. 

In the male, the late W. J. Morton used a zinc or copper ionization of 
the entire urethra. Breiger, of Berlin, employs prolonged radiant light 
directed on the urethra. 

Diathermy has been applied with one surface suprapubic and one metal 
sound electrode, using low currents of 100 to 300 milliamperes for thirty 
minutes. Great caution is necessary with this technic. 

Complicating orchitis and epididymitis are treated by radiant light 
and diathermy, a cup-shaped electrode being applied to the scrotum with 
the indifferent electrode on the lower abdomen. 

Prostatitis. —Certain types of this disease can be efficiently treated by 
physiotherapy. Malignancy must be ruled out. Simple baggy enlarge¬ 
ment yields most satisfactorily to the application of the Morton wave cur¬ 
rent applied per rectum. In dense fibrous infiltration only the accompany¬ 
ing edema can be relieved. 

Massage of the prostate can in no other way be as well or conveniently 
done as with the Morton wave current. This indication is so common that 
it is surprising that this best of all methods has been so greatly neglected 
by the profession. The wave rate should be given at two per second. This 
method is painless, cleanly and thorough in its results. The metal rectal 


524 


COMBINED METHODS OF PHYSIOTHERAPY 


electrode may be inserted by the patient and is easily retained. The posi¬ 
tive pole of the static machine is used with the terminal separation slowly 
increased as the tolerance of the patient permits. 

Painful inflammations are best treated by diathermy using a rectal 
metal or non-vacuum glass electrode and a surface plate on the abdomen. 
Six to twelve hundred milliamperes are used for twenty minutes. 

Victor C. Pedersen, of New York, reports a number of cases of 
gonorrheal prostatitis in different stages in which most satisfactory results 
were secured by electrotherapeutic measures. He uses the high vacuum 
glass prostatic electrode attached to the negative pole of the static ma¬ 
chine. The use of a short spark gap of one inch proved soothing in acute 
cases. Where deep massage is indicated the positive pole and wide spark 
gap is used. 

Nephritis. —In acute nephritis the stimulation of the excretory func¬ 
tion of the skin is all-important. The radiant light cabinet bath or body 
bath, with superheated dry air with the patient recumbent, is one of the 
most efficient methods we have of accomplishing this result. 

These treatments should be given at a relatively low temperature and 
may be continued for several hours when necessary. The value of this 
procedure in hospital practice can hardly be overestimated. 

It would seem logical that in certain cases diathermy of the kidney 
should prove of value. The writer used this method in three cases which 
were in a state of coma. Two were apparently quickly and markedly 
improved and made a complete recovery from the attack. The other case 
was not improved. No estimate of its value can be made from these 
results other than the fact that they would seem to justify further employ¬ 
ment of this measure. A large plate, about six by ten inches, was placed 
on the abdomen and a smaller one, four by seven inches, over each kidney, 
in turn, using 1,200 milliamperes for twenty minutes on each. 


DISEASES OF GLANDS; DISEASES OF THE EAR; AND SCARS 

Cystic Goiter. —G. Betton Massey, of Philadelphia, uses drainage 
and ionization to destroy the sac. A preliminary aspiration is made to 
confirm the diagnosis and only those cases with fluid present are treated 
by this method. 

With the patient recumbent on the operating table, an indifferent pad 
is placed beneath the back and connected temporarily with the anode of a 
direct current apparatus. The skin over the most prominent part of the 
cyst is anesthetized over an area of about a square inch by endermic 
injections of a 2 per cent solution of either procain or apothesine, and a 
rather large aspirating needle is prepared to function as a cathode, as 
well as an aspirator, by winding the end with a sufficient length of No. 34 


525 


DISEASES OF GLANDS; SCARS 

copper wire about its shank near the attachment end, the wire acting 
as a conductor. The other end of the wire is attached to the cathode 
binding post. 

The aspirating needle, attached to its aspirator as well as to the 
electric apparatus, is carefully inserted into the cyst and the contents of 
the latter withdrawn. A fully developed cyst, with little or no paren¬ 
chymal tissue overlying it, usually collapses at this time. The needle, 
still in position within the cyst, is detached from the aspirator and em¬ 
ployed as a cathodic electrode, 10 to 15 milliamperes of current being 
turned on for ten minutes. This will produce a frothy liquefaction of the 
tissue in immediate contact with the needle, making subsequent insertion 
of the ionizing probe easy after the current has been turned off and the 
needle removed. 

At the completion of the aspiration and the electrolysis of the sinus, 
the wire to the indifferent electrode is changed to the cathode binding 
post and a short zinc probe with fine point, made from one thirty-second 
inch zinc*plate, is freely coated with mercury by amalgamation, attached 
to the anode binding post by fine wire, and inserted into the sac through 
the needle opening. A current of 5 to 15 milliamperes is then turned 
on and maintained for a quarter of an hour. The site of puncture is 
dressed, after the application and daily thereafter, with dilute zinc oxid 
ointment and gauze. The patient may remain ambulant. 

In three days a second ionization with mercury on the zinc probe 
is applied through the opening in the tiny slough. At the end of a week 
or ten days, the skin slough will be found loosened, revealing a minute 
sinus leading into the cyst, through which additional mercury ions should 
be diffused every third day from an amalgamated zinc probe passed into 
the sac. At the end of the third week the zinc probe should be insulated 
with fused sealing wax before amalgamation, the insulation leaving a 
half-inch at the point bare. The purpose of the insulation is the pro¬ 
tection of the sinus walls from further enlargement by confining the ion 
diffusion to the sac itself. During the course of the treatment the later 
insertions of the ionizing probe are made less painful by placing a drop 
of cocain or procain solution on the opening, five or six minutes prior to 
its insertion. All ionizations are of fifteen minutes’ duration, with a 
current strength, dictated by the sensitiveness of the patient, of between 
3 and 10 milliamperes. The final ionizations, during the fifth to the 
seventh week, are not much more than probings, with a little current 
for sterilization, until the wound closes fully from the bottom. This 
technic may be varied by making a free opening with a small bistoury 
and immediate ionization at the first application; or by the use of the 
mercury ion alone, held in amalgamation on a solid gold probe. The use 
of the zinc ion, in association with the mercury ion, as described above, 
is thought, however, to be more quickly destructive of the cyst wall than 


526 


COMBINED METHODS OF PHYSIOTHERAPY 


the mercury ion alone. But, in any case, the mercury ion is essential 
to the method, on account of its high antiseptic action. 

Exophthalmic Goiter. —S. Solis-Cohen concludes that, because of the 
varying and little known pathogenesis of this disease, no single method 
of treatment will ever suffice in all cases. He divides them roughly into 
the highly toxic type, where the ocular, cardiac and nervous symptoms 
predominate and the gland is distinctly hyperactive, and a sluggish type, 
in which gland function is not hyperactive regardless of its size. 

Brustad, Snow, Massey and other writers report favorably upon the 
effect of the galvanic and Morton wave current in various types of goiter. 
In our small group of cases of the active toxic type, we have used nega¬ 
tive galvanism and static effluve with good results, but in too small a 
number of cases to form a definite judgment of the general value of 
these procedures. In the absence of hyperthyroidism, ionization from 
potassium iodid, using the negative pole, has produced good results. Cohen 
uses the static sparks and static resonator effluve directly on the gland in 
this type of goiter. These indicated conservative methods, together with 
others not within the scope of this writing, should logically be tried before 
radical surgery, except in those rapidly developing cases of toxic type 
in which it may still be safe to operate. 

Adenitis. —In both simple and tuberculous adenitis of the cervical 
glands, attention must be directed to the possible removal of tonsils and 
adenoids, hygienic and other indicated procedures. In the treatment of 
tuberculous adenitis, Miller reports the results from a regime of helio¬ 
therapy, as given in the combined French Sanitarium reports, as 74 per 
cent cured. Hyde and Lo Grasso report 78 per cent of cures in some two 
hundred cases treated by the same method. The carbon arc and ultra¬ 
violet light have been used with similar results. There seems to be a 
preponderance of opinion that conservative measures should be thor¬ 
oughly tried out before resorting to operation. Glands in the superficial 
chains should be treated by compression with the surface applicator from 
the water-cooled lamp. General irradiation with the air-cooled lamp is 
advisable. Results by this method have been very satisfactory where the 
main foci of infection were removed. Persistent sinuses may be healed 
up by the combined surface and internal administration of water-cooled 
ultraviolet light through the sinus applicators. 

In several cases of inguinal adenitis in various stages, the local com¬ 
pression application from the water-cooled light yielded excellent results. 
Glands that had begun softening before light was applied were found, upon 
later incision, filled with serum instead of pus. 

The Ductless Glands. —The subject of the endocrine system, and the 
various disorders of function to which it is subject, forms too large a 
topic to be discussed in detail here, and too little work of scientific value 
in the application of physiotherapeutic measures to these glands has yet 


527 


DISEASES OF GLANDS; SCARS 

been done to warrant definite conclusions. It seems, however, as logical 
to stimulate a poorly functioning gland by means of diathermy, the effect 
of which measure can be so definitely localized, as to supply artificially the 
body with the gland extracts. Already attention has been directed to 
the possible effect of X-ray upon various glands of the endocrine system. 

Otitis Media. —In the beginning of the acute stage the immediate and 
intensive application of radiant light is one of the most satisfactory pro¬ 
cedures in the whole range of physiotherapy. If taken sufficiently early, 
the inflammatory condition may often be immediately stopped. In later 
cases indications for puncturing the drum remain as usual, but radiant 
light should be applied and persisted in, whether or not this procedure 
is necessary. Any form of electric light, even the ordinary incandescent 
bulb, will serve in an emergency for home treatment. The hundred candle- 
power hand lamp placed on a pillow, eighteen or twenty inches from 
the head, is very efficient. Few cases so treated from the beginning will 
go on to suppuration or mastoid involvement. The effect upon the patient 
has been described, by otologists who have used it extensively, as being 
out of all proportion to the amount of heat developed in the aural canal. 

In chronic cases, A. R. Friel, of the London Royal Hospital, states 
that zinc ionization is a method by means of which the tympanum can be 
disinfected without irritation, and a large proportion of his uncomplicated 
cases cleared up in one or two treatments. Both ultraviolet light and 
diathermy have been used in chronic middle-ear disease with varying 
degrees of success. With a cuff electrode around each wrist and the 
patient’s little fingers inserted into the external auditory canals, a mild 
diathermy can be passed directly through the affected region. About 
300 milliamperes should be used for fifteen minutes. This should be fol¬ 
lowed by local application of ultraviolet light through a small sinus appli¬ 
cator inserted part way into the canal. Success by these methods depends 
upon the amount of destruction that has taken place and there can be 
no question that they are distinct adjuncts to the routine procedures. 

Catarrhal Deafness. —One useful adjunct in the treatment of this 
condition is the application of slow, gentle, sinusoidal current after the 
technic of William D. McFee, of Haverhill. A metal electrode is placed 
on the tongue and a pledget of cotton soaked in saline and wrapped 
around a small electrode is gently placed in the ear. A gentle and efficient 
massage of the drum is obtained by the use of a very moderate amount 
of current, easily tolerated by the patient for ten to fifteen minutes. 

Scars. —The minimizing of the amount of cicatricial tissue formation 
is one of the best accomplishments of modem surgery. The excision 
en masse of infected and macerated tissue was one of the essential lessons 
of the War. The physiotherapist is concerned in so modifying the re¬ 
maining scar tissue as to make it as little of a handicap as possible in 
the motor life of the patient. The functional results secured by a regime 


528 


COMBINED METHODS OF PHYSIOTHERAPY 


of physiotherapy often determine whether or not a second excision of 
the cicatrix is necessary. 

The aims of the employment of physical measures on scar tissue are: 

1. To promote increased vascularization. 

2. To decrease the density of the fibrous tissue. 

3. To free surrounding structures, nerves, tendons, muscles and liga¬ 
ments from cicatricial adhesions. 

4. To increase the thickness and strength of the newly formed epi¬ 
dermis. All physiotherapeutic technic applied to scar tissue must be very 
carefully graded for optimum effect. Only a few of the measures and 
none of the dosages indicated for normal tissue may safely be employed. 

By the use of properly graded doses of galvanism from the negative 
pole we may accomplish two or three of our indications. It will be re¬ 
membered that the action of this pole is to soften and liquefy scar tissue 
and to promote vascularity. The first effect would, naturally, also aid in 
freeing other structures imbedded in the scar. The chlorin ion is an 
additional aid in accomplishing this result, and a slightly stronger salt 
solution may be used on the negative pole than is necessary on the posi¬ 
tive to secure easy conduction of the current. The active electrode cover¬ 
ing the scar must be prepared with unusual care. See that it is thoroughly 
and evenly moistened and its surface smoothly applied to all parts of 
the scar. The current of 5 to 15 milliainperes should be employed for 
from thirty to forty minutes and the electrodes will probably need re¬ 
moistening during the treatment. 

Radiant light from either the high or low-candle-power lamp, placed 
at half again the distance usually used, will promote the vascularity of 
the newly formed integument. The ultraviolet light from the air-cooled 
lamp, in mild and often repeated doses, will stimulate skin cell growth. 
This should be given with the all-mercury burner, at about thirty inches 
for one minute with fifteen seconds’ daily increment. With the mercury- 
tungsten burner it should be applied at a distance of forty inches with 
ten seconds’ daily increase. Diathermy is an aid to both the softening 
and vascularization of the cicatrix and should be applied by the cuff or 
zone method above and below the involved area. The impoverished circu¬ 
lation in dense scar tissue means poor and sluggish diffusion of heat, 
therefore a low current strength of 300 to 500 hundred milliamperes and 
sufficient area of the electrodes should be selected so that the current 
density will not be over 50 milliamperes per square inch. 

For the purpose of loosening the scar from surrounding structures 
no apparatus quite approaches in effect the use of the heavy long-stroke 
motor vibrator. The vibrations are given around the scar, working cen¬ 
trally as far as tenderness will permit. Static sparks, Morton wave, mas- 


POSTURAL DEFECTS 


529 


sage and even at times the sinusoidal current may be employed for 
similar effect. The use of intensive local heat from superheated dry air 
or the paraffin bath is apt to produce large blisters and destroy the newly 
formed skin. 


POSTURAL DEFECTS 

The effect of faulty posture in lowering the working efficiency of the 
individual is pretty well established. Marked increase in total fatigue 
ensues when the mechanics of weight hearing are faulty. The functions 
of the respiratory system and gastro-intestinal tract are interfered with 
to a large degree by the habitual assumption of bad posture. Visceroptosis 
is often due primarily to this cause. It is the opinion of the writer that 
many of the so-called organic or structural orthopedic types of spinal 
defect, typified by scoliosis, are nearly always postural or flexible in 
type at first, but become “fixed” by the effect of long-continued habitual 
malpositions of the soft tissues. Only in associated calcium deficiency 
or cases of severe degree and long standing do bony changes occur. This 
point emphasizes the value of early treatment. 

The correction of faulty posture especially in school children lies 
distinctly in the field of preventive medicine as well as in that of thera¬ 
peutics. Physicians, parents and educators are not yet fully awake to the 
vital importance of this subject. 

The general indications are the same in nearly all of the types of 
postural defects; they are: 

1. To reeducate the “muscle sense” to the correct attitude. 

2. To improve the muscle tone and vigor of the entire body. 

3. To stretch those muscle groups which have been allowed to shorten 
by the defective carriage. 

4. To strengthen, and thereby shorten, the physiological opponents 
of the contracted group. 

5. To increase the general flexibility and maintain the full range of 
movement in the joints. 

To accomplish these results, we employ orthopedic and general exer¬ 
cises, massage and electrotherapy. Other physical measures, considered 
in their respective sections, are used when rickets or infantile paralysis 
are associated conditions. Much space is given to the severe types of 
deformity in the orthopedic texts but very little information on the 
causes, diagnosis and treatment of the very common postural defects 
appears in the literature. For this reason a brief general discussion 
of each type of defect is given with the treatment regime. 


530 COMBINED METHODS OF PHYSIOTHERAPY 


Head and Shoulders.—The combination of round shoulders and for¬ 
ward position of the head is the most common postural slump. Defects 
of hearing and vision and improper sitting in school are the greatest 
causes of the poor posture. In slight degrees of round shoulders, the 
louver angle of the scapulae, only, may be prominent. In the more severe 
types the entire inner border assumes the “winged scapulae” position. 
The correction of the head position is secured by the exercises of head 
retraction. The child thrusts the head forward chin up, and retracts 
the head slowly and forceably bringing the chin down. This may be 
made a resistive exercise by the child supporting himself by the hands, 
arm’s length from a wall, the operator standing behind him and resisting 
the head retraction, hand or hands placed behind the child’s head. A 
great deal has been written about the fundamentally correct posture. 
Many of the directions given are too intricate for a child to follow. The 
single command to raise the sternum to the utmost height will auto¬ 
matically bring the child into the correct posture. The cooperation of 
parent and teacher to insist continuously upon the correct attitude is 
essential in the formation of correct postural habits. The correction 
of the round shoulders is obtained by the use of the group of shoulder 
exercises considered in the next topic. Shoulder braces remove all exer¬ 
cise from the already weakened upper back muscles and often obtain 
their fixations on the movable lumbar spine inducing lordosis. They 
should be avoided, if possible. 

Kyphosis.—This position of increased flexion of the dorsal spine is 
nearly always accompanied by round shoulders. It may be considered 
simply as a greater degree of the former in which the spine plays a part. 
The etiology is the same, but there is usually some definite weakness of 
body structure as well. Such lack of tone as accompanies undemutrition, 
too rapid growth or intercurrent illness, etc., is associated with some 
repeated strain on the body’s structure. 

Round Shoulder and Kyphosis Exercises 

1. To reeducate muscle sense 

a. Place child before mirror. Assist him in assuming the correct 
posture. 

h. While he attempts to retain good posture, march him around 
the room and return to mirror, making necessary corrections in 
attitude. 

c. With his back to the mirror, the child is instructed to assume 
the correct attitude, is faced toward the mirror and attempts 
his own correction. 

2. To improve general muscle tone 

a. General light class exercises. 

h. Athletics and games in moderation without exhaustion. 


POSTURAL DEFECTS 


531 


3. To stretch the contracted pectoral muscles 

a. Child seated on stool, hands to neck; operator places foot on 
stool behind patient, knees against dorsal spine and makes 
retraction on elbows. 

b. Child stands in front of stall-bar uprights, grasping behind 
shoulders. Keeping head, shoulders and hips in contact he 
performs a deep knee bending and straightening. 

c. Child lies supine on plinth or narrow bench. Hands behind 
neck, operator from above presses down on elbows. 

d. Child suspended by hands from bar or ladder, operator places 
hands between scapulae and presses firmly forward. 

e. Child in front of horizontal or parallel bar, or behind slanting 
ladder, grasps shoulder high arm’s length in front. Without 
moving feet he falls forward to full arm hang. 

/. Pupil with spread grasp raises wand above head, lowers behind 
shoulders. 

4. To strengthen the stretched and weakened upper shoulder 

group. 

Qn Arms forward raise, sideward carry and slowly sideward lower 
keeping shoulders well back. 

b. Arms forward raise, forward bend (hands to chest, elbows 
raised and well back). Sideward lower with shoulder 
retraction. 

c. Arms forward raise, obliquely side-upward carry, sideward 
lower, slowly maintaining shoulder retraction. 

d. Arms forward bend as before, trunk lower forward, hands 
thrust forward and carried sideward in imitation of breast 
stroke swimming. 

e. Rotate arms completely outward forcing shoulders back. 

5. To increase general flexibility 

a. Hands suspension, spine twisting right and left by turning 
pelvis. 

b. Stride stand, arms sideward raise, trunk to the right bend, 
raise, to the left bend, raise. 

c. In same position trunk to the right turn, return, to the left 
turn, return. 

Lordosis.—Abnormal forward curve in the lumbar spine is often asso¬ 
ciated with and compensatory to kyphosis. High heels and excessive 
abdominal weight are also causes of this condition. The increased lumbar 
curve and pelvic inclination adds to the strain on the anterior abdominal 
wall which may become relaxed and weakened. This is one of the 
contributing factors to visceroptosis and chronic constipation and adds 
greatly to fatigue in standing. 


532 


COMBINED METHODS OF PHYSIOTHERAPY 


Exercises for Lordosis 

1. To stretch the shortened lumbar erector spina? 

a. Long sitting, legs extended in front. 

2. To strengthen the abdominal muscles 

a. Supine lying, hands at sides palms down, double knee bending 
and straightening. 

b. Double leg raising and lowering slowly. 

c. Sitting up and lying back. 

d. Flex knees to chest, extend feet over head, raise pelvis from 
the table and return. 

e. Elex and extend knees alternately and rapidly in imitation 
of bicycling. 

/. Hands suspension, double knee raising. 

Scoliosis. —Nearly 20 per cent of children show some degree of 
scoliosis. In the examination of from one to two thousand preparatory 
school girls I found about 22 per cent had lateral curvature. Like every 
other condition it is difficult to diagnose but easy to cure in its incipiency. 
Those curvatures which straighten out on hand suspension have been 
termed “functional, flexibility or postural,” curves, the others “structural 
or organic.” Postural cases outnumber the structural type by about ten 
to one, but are often overlooked in hasty physical examinations. 

In addition to the causes mentioned under anteroposterior deformities, 
most of which apply here as well, we have unilateral weight bearing and 
infantile paralysis affecting the back as common causes. Most curves 
start as single “C”-shaped curves and, if untreated, often develop into 
double or “S”-shaped deformities due to compensatory straightening of 
the pelvis or head. 

Many patients carry slight scolioses through life with no ill effect 
but they are sources of very great potential danger. I have seen slight 
curves become great in degree and fixed in character very quickly follow¬ 
ing wasting illness, infections of the rheumatic group and other conditions 
which suddenly lower the body’s resistance. Many schools and colleges 
are now thoroughly examining for postural defects and following out 
carefully prescribed individual exercises. When this procedure is uni¬ 
versal a great deal of deformity now present will be prevented. Such 
examinations should be started in the grammar schools. 

Diagnosis, —In the examination of the back we rely upon the following 
five signs: 

1. The scapula tends to be higher, more prominent and further from 
the dorsal convexity. 

2. The arm-waist angle is less on the side of the curve. 

3. The shoulder on the convex side is usually higher and the hip on 


POSTURAL DEFECTS 533 

the lumbar convexity less prominent when compared with the opposite 
side. 

4. The marked spinous processes show a deviation from the plumb 
line in all pronounced curves. In slight ones absence of this sign does 
not rule out a curve. 

5. Prominence on one side in the mid-dorsal or lumbar region brought 
out by trunk forward bending is a sure sign of vertebral rotation and is 
the most reliable evidence of scoliosis. A prominence indicates a curve 
to that side in the region in which it occurs. 

The subject of vertebral rotation has caused more disagreement than 
any other phase of this condition. It can positively he stated that there 
is no lateral displacement without some degree of rotation and it is pro¬ 
portionate to the amount of lateral deviation. 

All orthopedists agree that in an advanced fixed curve the bodies rotate 
toward the convexity, thus turning the spinous processes hack toward 
the normal position and masking to some extent the amount of the curve 
and, at the same time, causing the ribs to become prominent on the affected 
side. 

There is no such agreement in regard to the rotation occurring in 
a flexible curve. Lovett, of Boston, has contributed more than any other 
single individual to our knowledge of the subject. His experiments on 
a model performing trunk bendings, sitting on inclined seat, etc., seem to 
show that in a normal lateral trunk bending the bodies do rotate toward 
the concavity of the curve produced. This hypothesis he applies to flexible 
lateral curvature as being the same thing. In his teaching the writer 
has stated the cause of rotation to be primarily the result of the fact that 
when a column of blocklike bodies is displaced in part so that the center 
of gravity does not fall through the center of all the bodies, those so 
displaced rotate away from the line of weight hearing. So in a left total 
curve the thick front of the vertebral bodies rotates to the left away from 
the center of gravity which now falls to the right of their center. Ho such 
force is at work in a normal trunk bending, moreover flexible curves 
are slight and hard to detect because the amount of lateral displacement 
is nearly equaled by the rotation, so that the spinous processes fall very 
nearly in the midline. If reverse rotation took place in these cases, the 
spinous processes would swing widely out and their line, the apparent 
curve, would be greater than the displacement of the centers of the bodies 
of the vertebrae (the real curve) and the diagnosis easy. Furthermore 
as a curve is becoming fixed and the re-rotation claimed by those who 
hold this theory taking place, the apparent curve would necessarily become 
less when as a matter of fact we know that in untreated cases the ten¬ 
dency is for the curve to increase. It is believed that a flexible curve 
becomes rigid first by the sclerotic changes induced in the muscles allowed 


534 


COMBINED METHODS OE PHYSIOTHERAPY 


to *aaintain contraction on the concave side, then by changes in the liga- 
mentlj twd intervertebral discs, and lastly, and only if bony softening is 
present, the bone becomes distorted. At what point in this gradual “set¬ 
ting” process does re-rotation begin ? Given two left total curves of the 
same amplitude in two patients of equal age, one of which straightens out 
under suspension, the other not, does it seem logical that a diametrically 
opposite rotation should occur in them ? 

I have gone rather deeply into the subject of rotation because proper 
treatment is dependent on a knowledge of it. The bodies would rotate 
still more were it not for the fact that the articular facets are set in 
different planes. The flexion of the spine forward unlocks the articula¬ 
tions and allows increased rotation to take place, thus bringing out the 
prominence on the back. 

The treatment of scoliosis is not extremely difficult nor does it require 
cumbersome and complicated mechanotherapeutic apparatus which is being 
less and less used in physiotherapy. 

Exercise is taking first place and gaining favor as our main dependence 
and should always he used between casts if they be deemed necessary. 

1. Exercises to reeducate the muscle sense. 

a. Use mirror as in kyphosis. Place emphasis on erect head, 
even shoulders and hips. 

b. Return to mirror at the end of the exercise program, having 
child attempt good posture with eyes closed and make self¬ 
correction. 

c. Teach the position of “self-correction” in each individual case. 
This position consists of stretching vigorously obliquely side- 
upward the arm on the dorsal concavity and the opposite hand 
is worked as far back as possible and pressed on the lumbar 
concavity, in total curves. In double curves the child’s hands 
are pressed against the body in the posterior axillary line, the 
upper against the dorsal and the lower against the lumbar 
convexity. 

2. These children also should do general setting-up work and bilateral 
muscle strengthening. 

3. Stretch the muscles on the concave side. 

a. The child assumes his self-correction attitude and with hips 
fixed against some convenient object, such as a table, bench 
or chair, performs lateral trunk bending toward the lumbar 
concavity. 

b. With grasp on stall bars or horizontal bar, chest high, the 
body is lowered to full arm’s length, both legs toward the 
lumbar convex side. 

c. Spring sitting at side of stool, trunk inclined forward, the arm 


FOOT DISABILITIES 


535 


on the side of the dorsal concavity is stretched vigorously for¬ 
ward and the leg on the side of the lumbar concavity is stretched 
backward to the fullest extent. 

d. The child assumes the self-correction attitude and walks sev¬ 
eral steps on tiptoe, stretching the spine to the utmost. 

e. Hook-lying supine on table, knees over the edge, both hands 
overhead. Operator stands behind pupil grasping both hands, 
stretches spine fully. 

/. The child hangs suspended from bar, operator from behind 
exerts counterpressure on dorsal and lumbar convexities push¬ 
ing child forward. 

g. Strap table. Shoulders and pelvis strapped toward the con¬ 
vexity in those regions, two central straps exert traction from 
below and toward the concavity. 

4. To increase flexibility, exercise for spinal flexibility as given under 
Kyphosis. 

Other Physiotherapeutic Measures. —In all cases of long standing the 
muscles on the concave side tend to become first spastic and later undergo 
chronic fibrous myositis. These changes can be to a large extent prevented 
by the use of radiant light and heat, high-frequency, Morton wave and 
static sparks and massage with the same technic already given for these 
modalities. In severe cases requiring casts the value of these measures 
coupled with exercises cannot be overestimated. The circulation within 
the muscles and their general tone becomes greatly impaired under the 
cast, and a period of intensive physiotherapy should he given before put¬ 
ting on another cast. 

All of these exercises need not be given in a single program but at 
least one from each different group must he chosen to meet all indica¬ 
tions. The stretch-walk and spring-sitting exercises should be taken with 
the utmost intensity for only brief intervals of time. 


FOOT DISABILITIES 

This group of conditions, most of which consist in the last analysis 
of toxic, atrophic, or traumatic myositis or arthritis, are especially ame¬ 
nable to treatment by physiotherapy which may lead to complete restora¬ 
tion of function. The accepted orthopedic measures of providing arch 
supports, on the other hand, more often attain symptomatic relief rather 
than cure. A brief review of the etiology and modern methods of treating 
these common and disabling conditions is well worth while. 

The foot is designed to support the body and to enable it to move over 
various kinds of surface. Those who still use their feet in natural fashion 


536 


COMBINED METHODS OF PHYSIOTHERAPY 


have strong and well-developed muscles and ligaments, broad forefeet, and 
grasp with facility uneven surfaces upon which they walk. The fact 
that in standing and walking they point the feet straight forward or 
slightly inward is of importance. 

A study of the changes in the use of the feet induced by modem 
civilization, and the conditions under which they must do their work, 
will reveal some of the reasons for the great prevalence of foot disability. 

In the first place, we teach our children to evert the feet. In this 
posture the weight is transmitted to the inside of the foot over the arch, 
instead of through the forefoot. Armitage Whitman believes this attitude 
to be the underlying cause of weak feet. It is obviously one of the im¬ 
portant factors in bringing about this condition. In walking with feet 
everted, the outer side of the heel first strikes the floor, then the weight 
is transmitted diagonally forward and inward to the arch, causing a severe 
cross strain. If high heels are worn when the feet are everted, the strain 
becomes very greatly increased. 

We incase the feet in shoes, not one of which is the shape of the human 
foot. Certain requirements must be met to reduce to a minimum the 
deforming influence of the shoe. It must have a sole sufficiently thick 
to protect the foot from the stone pavements on which we are condemned 
to walk, and to prevent the sides of the sole from curling up, making a 
hollow into which the anterior arch tends to fall. The toe cap should be 
full enough to allow free movement of the toes. Such point as the shoe 
possesses should be in front of the great toe and not in the middle of 
the foot, which crowds the big toe into the hallux valgus position. The 
shoe must at all times be long enough to prevent the toes being cramped. 
Hammer toes often develop in children whose feet grow in length before 
the shoes are worn out. 

The heel is a vital factor in proper shoeing. Especially is it necessary 
to have a heel with a reasonable amount of cross surface. Otherwise, 
with any height it becomes a stilt, on which the patient is doing a finely 
coordinated and very fatiguing balance exercise, using groups of muscles 
in which the circulation is poor and therefore recovery from fatigue slow. 
With the high heel also there is a tendency for the forefoot to become 
crowded forward and bear undue weight, as the instep resting on the 
steep slope of the shank cannot support its share of the weight. Lastly, 
and perhaps most important, is the tendency of the high heel to throw 
the calf muscle group into a state of partial contraction, which position 
long held becomes a factor in the structural shortening of these muscles, 
producing muscle-bound feet. Lovett calls attention to the fact that the 
arch of the sole of the shoe is often too low to support that of the foot 
and is, therefore, one of the causes of foot strain. 

In addition to the exercise-preventing and deforming influence of 
the shoe, we have added the hard-wood floor and cement pavement for full 


FOOT DISABILITIES 


537 


measure. The wonder is, not that there is so much foot trouble, hut that it 
is not universal. 

Poor mechanics of walking, adopted to avoid pain from corns, callosi¬ 
ties, sprains, etc., must be recorded among the causes of foot strain. 

I have had many cases which verify the point so well brought out by 
Henry W. Frauenthal of New York, that the toxins of recent disease or 
specific infection, as well as those from foci of infection in teeth, tonsils, 
etc., play a leading role in painful foot disabilities. The influence of these 
toxins in retarding recovery, when there is some other more obvious cause 
present as well, is constantly overlooked. 

We have then the foot predisposed to strain by the impossibility of 
normal development, used improperly, and attacked by the toxins of dis¬ 
ease, causing the patient to seek relief. It is quite the usual thing for 
him to pass through the hands of several shoe-store “foot experts” and a 
few chiropodists before reaching the physician. If the trouble is en¬ 
tirely local the foot appliance provided for the patient will often give 
marked relief. It is because such plates, etc., are not curative as a rule 
in the long run, and because of the very frequent presence of other than 
local cause, that a real cure is seldom attained. 

In considering diagnosis, a further point made by Frauenthal is of 
value. He states that, when pain in the feet comes on suddenly, we must 
suspect injury or infection, whereas if the onset of symptoms is gradual 
there is strain of muscles or ligaments. E. A. Kich, of Tacoma, Washing¬ 
ton, records the arch impression and compares it to the amount of ankle 
valgus, pointing out how often painful feet occur with marked valgus of the 
ankle, and with cavus rather than with planus deformity. Lovett found 
no change in the arch impressions of a large number of the eight hundred 
nurses he pedographed after the onset of pain in the feet. He refutes the 
accepted theory that there is necessarily an elongation and broadening 
of the sole of the foot in these conditions. I have never felt that the 
taking of an arch impression was essential to diagnosis. 

In the examination of the forefoot, sharply localized pain under the 
second, third or fourth metatarsophalangeal joint is indicative of anterior 
arch trouble, but may point to an inflamed or broken sesamoid or to 
osteo-arthritis from any cause. Occasionally we are dealing here with pain 
referred from the main arch. 

When the pain is located in the longitudinal arch under the scaphoid, 
the presumption is that this arch is under strain. It is important to re¬ 
member that strain is often present in the naturally high arch before 
there is any sign of flattening, and is due to tension at the periosteal 
attachments of the ligaments or in the plantar muscles. 

Examination is never complete without testing the dorsal flexion of 
the foot. Have the patient sit with knees fully extended. Grasp the 
forefoot firmly, invert, then flex, being sure the patient’s muscles are 


538 


COMBINED METHODS OF PHYSIOTHERAPY 


relaxed. Estimate the angle between the rear of the leg and the outer 
part of sole. This angle should be less than a right angle—75° to 85°. 
When the flexion is limited to 90° or more you are dealing with a muscle- 
hound foot. This condition is present in about 30 per cent of women 
and 10 per cent of men seeking relief from painful feet. In women I 
believe it to be the greatest single factor in the causation of foot strain 
and to he in itself the underlying reason for a large part of the eversion 
of the feet described by Lovett. This is the sequence of events: In the 
normal step with feet straight, there is a time just before the rear heel 
is raised when the dorsal flexion of the foot is less than a right angle. 
It is at this point that a short calf muscle is subjected to undue tension 
which may or may not he recognized by the patient. A slight eversion of 
the feet will relax this tension. If the condition is progressive, increased 
eversion becomes necessary with the intense strain on the arch outlined 
above. Sooner or later symptoms of foot strain appear. 

Treatment. —Our attention should be directed first to the removal 
of the cause. The acute toxic or infectious conditions are generally ob¬ 
vious, but it is necessary that chronic conditions and foci of infection 
be constantly kept in mind as factors which delay recovery. The proper 
mechanical use of the feet and relative rest must be insisted upon where 
possible. 

Anterior metatarsalgia is treated by intensive radiant light and heat 
or paraffin bath, high-frequency, static sparks and massage. A felt pad 
may be strapped on or held by an anterior arch collar when necessary. 

In the treatment of the main arch, the Thomas heel, extended one- 
half to three-quarters of an inch and raised one-eighth to one-quarter 
inch on the inner side, is useful in nearly every case. Very rarely soft 
felt pads under the arch, or in cavus foot under the instep, may be used. 
Strapping with adhesive may be done as a temporary measure. It has 
not been found necessary to prescribe any arch plate whatever in the last 
three years. Occasionally a well-fitting arch already purchased was per¬ 
mitted while the local treatment was being given. 

Where the main arch is under strain we treat by radiant light and 
heat, 1,500 candle-power for fifteen minutes, high-frequency, or diathermy 
—given by means of one metal plate to the sole, and the other encircling 
the ankle—and massage. Exercise often makes these cases worse, when 
instituted before other means have allayed the inflammation in the tissues. 
For this reason exercise is delayed until the tenderness has largely dis¬ 
appeared. A very simple set of exercises are used: 

1. Stand, feet parallel—roll out. 

2. Walk forward on outer edge, toeing in. 

3. Toe in and rise on toes. 

4. Ground gripper walk. 


REFERENCES 


539 


The treatment of muscle-boimd feet is primarily aimed at stretching 
out the calf muscle group. It is the muscle and not the Achilles’ tendon 
that is short, except in cases of severe contracture. These muscles often 
feel hard and fibrous and are quite tender. 

We heat intensely with the 1,500 candle-power lamp, use diathermy 
through the calf by lateral plates 1,000 milliamperes for fifteen minutes 
each and finish by prolonged deep slow effleurage. Here the exercise, 
which consists of standing, feet parallel, arm’s length from the wall, and 
lowering the body forward, keeping heels on the floor, is begun as soon 
as the deep tenderness in the muscle has lessened. It is pushed as much 
as possible without setting up inflammatory reaction. 

When, as often is the case, we are dealing with a combination of 
foot strain and muscle-hound foot, we treat by a combination of the 
methods outlined, omitting Exercise 3. These are undoubtedly the cases 
that Lovett states are made better by raising the heel, and he points out 
how many times they are made worse by suddenly shifting to a so-called 
orthopedic shoe. These patients feel better with a higher heel because 
more slack is given the calf muscle, but the strain of walking and standing 
is increased and the new slack given may soon be taken up with a repeti¬ 
tion of the symptoms. 

What constitutes a cure? In the case of the arch it is the removal 
or modification of the cause, the allaying of the inflammation, and the 
rebuilding of the tone of the muscles and ligaments to carry without any 
artificial supports . whatever the weight they were designed to carry. In 
muscle-bound feet a cure consists in the removal of the local or constitu¬ 
tional cause of tenderness or inflammation, with the gradual stretching 
of the calf muscle group until a dorsal flexion of 90° or less allows the 
use of a moderately low heel without discomfort. 


REFERENCES 

Bainbridge, F. A. The Physiology of Muscular Exercise, Longmans 
Green & Co., 1919. 

Bainbridge, William Seaman. A Contribution to the Study of Chronic 
Intestinal Stasis, Med. Rec., Sept. 27, 1913. 

Barringer, Theodore B., Jr. Principles Underlying the Treatment of 
Heart Disease by Exercise, Journ. Am. Med. Ass., July 2, 1921. 
Baruch, Simon. Hydrotherapy, W. B. Saunders Co., 1920. 

Bordier, H. Treatment of Infantile Paralysis, Arch. Radiol. & 
Electroth., London, Dec., 1921. 

-Diathermy in the Treatment of the Stomach, Paris Med., Dec. 3, 

1921. 



540 


COMBINED METHODS OF PHYSIOTHERAPY 


Brustad, Ludwig A. Exophthalmic Goitre Successfully Treated by Physi¬ 
cal Methods, Am. Joum. Electrotherap. & Radiol., July, 1921. 
Buben, von, I. Thermo-penetration for Gonorrhea in Women, Zntralbl. 
f. Gynak., Leipzig, Oct,, 1921. 

Carr, Burt W. Graduated Exercises in Cases of Functional Head Dis- 
' turbances, Ibid., March, 1921. 

Clark, A. Schuyler. The Kromayer Light in the Treatment of Certain 
Diseases of the Skin, Journ. Cutan. Dis., June, 1919. 

Cohen, S. Solis. Some Ways of Using the Electrical Current in Ex¬ 
ophthalmic Goitre, Am. Journ. Electrotherap. & Radiol., Feb., 1921. 
Cumberbatch, Elkin P. Diathermy, C. V. Mosby Co., St. Louis, 1921. 
-Essentials of Medical Electricity, C. V. Mosby Co., St. Louis, 

1921. 

Deane, Col. H. E. Gymnastic Treatment, Oxford University Press, 
1915. 

DeKraft, Frederick. Report of Committee on High Frequency Currents, 
New York, Am. Journ. Electrotherap. & Radiol., Dec., 1920. 

-Action of Electrical Currents on Ductless Glands, Ibid., March, 

1920. 

Drew, Lillian Curtin. Individual Gymnastics, Lea & Eebiger, New York, 

1922. 

Folmer, H. C. High Frequency Currents in Therapeutics, Nederl. 

Tijdschr. v. Geneesk., April 30, 1921. 

Frauenthal, Henry W. “Painful Feet,” Journ. Am. Med. Ass., Nov. 22, 
1913. 

Griinbaum, R. Thermo-penetration in Intermittent Claudication, Wien, 
klin. Wchnschr., Oct. 21, 1920. 

Halsey, Robert H. Heart Disease in Children of School Age, Journ. 
Am. Med. Ass., Aug. 27, 1921. 

Hirsh, A. B. Diathermy an Aid in Empyema, Am. Journ. Electrotherap. 
& Radiol., 1921. 

-Diathermy in Some Long Bones, Ibid., Sept., 1921. 

Hirst, Barton Cook. Development of Infantile Uterus by Negative 
Galvanism, Ibid., Jan., 1920. 

Kyaw. Diathermy in Treatment of Gonorrhea in the Female, Med. Klin., 
vi, 1829, 1912. 

Lovett, Robert W. The Superstition of Elat Feet, Journ. Am. Med. 
Ass., April 10, 1915. 

Massey, G. Betton. Drainage and the Mercury Ion in Cystic Goitre, 
N. Y. Med. Journ., April 24, 1920. 

-Treatment of Cavernous Angiomata by Electrolysis, Am. Joum. 

Electrotherap. & Radiol., 1920. 

McMillan, Mary. Massage and Therapeutic Exercise, W. B. Saunders 
Co., Philadelphia, 1921. 






REFERENCES 


541 


Miller, Richard H. The Treatment of Tubercular Cervical Adenitis, 
Journ. Am. Med. Ass., July 29, 1922. 

Moorehead, John J. Traumatic Surgical Problems, Ibid., lxxvi, 1642, 
1921. 

Mosher, Elizabeth M. Intestinal Stasis, N. Y. Med. Journ., Oct., 1916. 
Nissen, Hartvig. Practical Massage and Corrective Exercise, F. A. Davis 
Co., Philadelphia, 1920. 

Oliver, E. Lawrence. Ultra-violet Light in Erythema Induratum, Arch, 
f. Dermat. u. Syph., Vol. YI, Nov., 1922. 

-The Use of Quartz Light in Dermatology, Boston, Aug. 5, 

1920. 

Pacini, A. J. Outline of Ultra-violet Therapy, Poole Bros., Chicago, 
1923. 

Palmer. Lessons in Massage, Wm. Wood, 1918. 

Pedersen, Victor C. Urology and Electrotherapy in Correlation, Am. 

Journ. Electrotherap. & Radiol., March, 1922. 

Plank, Howard T. Actinic-Ray Therapy, Brown Press, Chicago, 1921. 
Prevost, Capt. J. M. E. Physiotherapy in Treatment of Chronic Skin 
Disease, Am. Journ. Electrotherap. & Radiol., July, 1920. 

Rolfe, William A. Treatment of Puritus Ani by Ionic Medicine, Boston 
Med. & Surg. Journ., Aug. 14, 1919. 

Saberton, Claude. Diathermy, P. B. Hoeber, New York, 1920. 
Sampson, Major C. M. Teaching Notes, U. S. Public Health Service. 
Setzu, S. Diathermy and Stomach Functioning, Riforma, Naples, 
April 3, 1920. 

Sperling. Diathermy in Gynecology, Monatschr. f. Geburtsh. u. 
Gynaek., Berlin, May, 1921. 

Stewart, Harry Eaton. Treatment of Injuries to Athletes, Journ. Am. 
Med. Ass., April 3, 1920. 

-Physiotherapy in the After-Care of Fractures, Am. Journ. 

Electrotherap. & Radiol., June, 1922. 

-Place of Physiotherapy in Treatment of Common Foot Disabili¬ 
ties, Ibid., Feb., 1922. 

-Treatment of Football Injuries, Med. Rec., Oct. 15, 1921. 

-Diathermy in Pneumonia, Am. Journ. Electrotherap. & Radiol., 

Oct., 1922. 

—-Physical Reconstruction and Orthopedics, Paul B. Hoeber, New 

York, 1920. 

-Treatment of Scoliosis, Am. Journ. Electrotherap. & Radiol., 

Dec., 1920. 

-Effect on the Heart Rate and Blood Pressure of Vigorous Ath¬ 
letics in Girls, Am. Phys. Educat. Rev., Feb., 1914. 

Stowell, Frank E. Treatment of Chronic Ulcers, Boston Med. & Surg. 
Journ., Feb. 12, 1920. 










542 


COMBINED METHODS OF PHYSIOTHERAPY 


Titus, Edward C. Modern Treatment of Obesity, Am. Journ. 
Electrotherap. & Radiol., 1920. 

Toomey, N. Leukoderma Improved by Quartz Light, Missouri State 
Med. Ass., Journ., Dec., 1922. 

Tousey. Medical Electricity and Rontgen Rays, W. B. Saunders Co., 
Philadelphia, 1921. 

Turrell, W. J. The Principles of Electrotherapy, Oxford University 
Press, 1922. 

Wilson, May G. Exercise Tolerance of Children with Heart Disease, 
Journ. Am. Med. Ass., June 11, 1921. 

Wise, Fred. Ultra Violet Light Rays in Skin Disease, N. Y. Med. 
Journ., Eeb. 3, 1917. 

Wright, Wilhelmina C. Muscle Training in the Treatment of Infantile 
Paralysis, Ernest Gregory, Boston, 1916. 


CHAPTER XIII 


RADIUM THERAPY 

Thomas Ordway, L. Whittington Gorham, and Clinton B. Hawn 

Radium. —Since the discovery of radium in 1898, this source of 
energy has been utilized for the treatment of a great variety of both ex¬ 
ternal and internal diseases. The earliest, and perhaps the most useful, 
field of application was in dermatology, and as this form of therapy proved 
of value in treating some of the most intractable skin diseases, such as 
lupus and carcinoma of the skin, the result was that overenthusiastic 
claims were made for radium therapy even in many incurable diseases. 

The literature on radium therapy has now reached enormous propor¬ 
tions. Hot only are there a great number of articles but many volumes 
and even journals are devoted solely to radium therapy. To this litera¬ 
ture the reader is referred for any detailed account of the subject. In 
this chapter a mere outline of the technic used, the variety of conditions 
which have been treated, and the general results obtained can be described. 
The therapeutic application of radium was developed by the French, 
notably by Hominici, Wickham, and Hegrais. The Germans began the 
use of mesothorium 1 2 and elaborated other forms of radium therapy. 
Radio-active substances and their products have such remarkable physical 
properties that the discovery and investigation of them has radically 
altered even fundamental conceptions regarding matter. With this in 
mind and with the realization that radio-active substances and their prod¬ 
ucts are so varied and may be used for therapeutic purposes in the solid, 
gaseous, or liquid form, it is not surprising that they have within recent 
years been the subject of extensive scientific experiment and also of wide¬ 
spread clinical application, even to the degree of exploitation. 

1 Degrais has suggested the advantage of calling radium therapy ‘ Curie therapy 
as we now speak of Roentgen therapy when the X-rays are used in treatment. 

2 Mesothorium was discovered by Hahn in 1905. The initial cost of mesothorium 
is less than that of radium but it loses its activity in very much shorter time, the 
half-life period of mesothorium being about seven years, while that of radium is 
about 2,000 years. Therefore, at the present time the use of radium has for the 
most part replaced tfipt of thorium. 


543 





544 


RADIUM THERAPY 


Soon after the discovery of radium by the Curies it was found that 
radio-active substances produced effects similar in many ways to the Roent¬ 
gen ray. In 1901 Becquerel was burned by carrying radio-active material 
in his pocket. In 1906 the Laboratoire Biologique du Radium was 
established in Paris and here Dominici, Danne, Wickham, Degrais and 
their coworkers developed the therapeutic application of radium. In 1909 
the Radium Institute at London was established for the treatment of 
disease by radium. 

In Austria the government established a central station for the dis¬ 
tribution of various forms of radio-active material to the different clinics. 
There is also in Vienna a Radium Institute supported by private funds, 
for the strictly scientific study of radio-active substances. In the United 
States the names of Abbe, Morton, and Kelly were early associated with 
the development of radium therapy. In several of the larger cities, 
notably Boston, New York, Buffalo, Baltimore and Chicago, there are 
special institutes or hospitals devoted almost exclusively to research and 
the therapeutic application of radium. Here the amount of radium avail¬ 
able varies from 1 to 3 or more grams. In only very exceptional instances, 
however, are such large amounts used at one time in any particular case. 
In the great majority of pathological conditions 100 milligrams are suffi¬ 
cient, if properly employed, to produce such results as may be reasonably 
accomplished. 

Radium is an element in the strontium-barium group. Its properties 
are now quite generally known. It is a metallic element designated by 
the symbol Ra. Three of the commonest salts are the bromid, chlorid, 
and sulphate of radium. It is derived from uranium. Other members 
of the radio-active group are thorium and actinium. Radium is con¬ 
stantly undergoing transformations into other substances, that is, radium 
becomes successively emanation, radium A, B, C, D, E, F (or polonium) 
which is probably converted into lead. The rate of this transformation 
cannot be altered by any known process or condition. During these 
transformations, energy is radiated from the substances in the form of 
the so-called alpha, beta, and gamma rays, upon the various effects of 
which the therapeutic action depends. 

Alpha rays are positively charged atoms of helium. They travel at 
the rate of 20,000 miles a second. Their penetration is slight; indeed, 
they are stopped by even a thin sheet of writing paper. They may produce 
marked chemical change hut cannot be used practically in treatment except 
in superficial lesions of the skin. 

Beta rays are negatively charged electrical ions, electrons, like cathode 
rays, but of about the velocity of light (186,000 miles a second). They 
penetrate about 8 millimeters of tissue, but do not penetrate over 2 milli¬ 
meters of lead, or 1.2 millimeters of brass. They also induce chemical 
change in organic matter. 


INJURIES INCIDENTAL TO HANDLING RADIUM 545 


Gamma rays are not particles of matter but vibrations of the ether 
similar to ordinary light and to the X-rays but of much shorter wave¬ 
length and greater penetration. They are said to have less power than the 
alpha or beta rays to produce chemical change. 

In medical work we may use the three sorts of rays together or by 
appropriate screens exclude either the alpha or beta rays. Ten per cent 
of the gamma rays are absorbed by 1 centimeter of tissue. They readily 
pass through 1.2 millimeters of brass, only about 3 per cent being absorbed. 
In passing through metal screens, however, soft ‘ secondary beta rays are 
“generated.”. - These may be absorbed by placing filter paper, gauze or 
wood 1 centimeter or more in thickness about metal screens. In experi¬ 
mental work it is possible by means of the electromagnet to use the alpha 
and beta rays alone. Clinically, we can approximate this by varying the 
time of application and the thickness of the screens because of the 
relatively greater amount of alpha and beta than of gamma rays; 
the proportion is respectively 90, 9, and 1 per cent when no screens 
are used. 

Injuries Incidental to Handling Radium.—The increasing use of large 
quantities of radium for therapeutic purposes makes it important to 
describe the symptoms and signs which may be caused by working with, 
or even near radio-active substances, and to emphasize the importance 
of these as occupational injuries. Suggestions are offered so that more 
serious late effects may not result. 

Rutherford states that “Walkhoff first observed that radium rays pro¬ 
duce burns of much the same character as those caused by Roentgen rays. 
Experiments in this direction have been made by Giesel, Curie and Bec- 
querel and others with very similar results. After handling radium there 
is at first a painful irritation, then inflammation sets in, which lasts 
from ten to twenty days if suitable precautions are not taken. This effect 
is produced by all preparations of radium, and appears to be due mainly 
to the alpha and soft beta rays. Care has to be taken, therefore, in han¬ 
dling radium on account of the painful inflammation set up by the rays. 
If a finger is held for some minutes at the base of a capsule containing a 
radium preparation, the skin becomes inflamed for about fifteen days and 
then peels off. The painful feeling does not disappear for two months.” 

Although these rather acute reactions due to radium are apparently 
well known to physicists working with radio-active substances and con¬ 
siderable experimental work has been done on animals by biologists, to 
show the histological changes produced, very little attention has been paid 
to the more chronic changes. With the increasing use of large quantities 
of radium, attention should be called especially to these changes, to which 
those handling radium are subject, A proper realization of this fact is 
necessary, not only because of the annoyance and discomfort caused by the 
less serious effects of radium, but because, with the analogy of the serious 


54C 


RADIUM THERAPY 


late effects of X-ray burns in mind, a warning should be sounded against 
possible similar results from radium, such as atrophy, intractable ulcera- 



A B A C D 


Fig. 1.—Devices for Holding Brass Capsule to Avoid Contact of the Fingers. 
A, watchmaker’s vise, filed out to grasp brass capsule in which non-corrosive steelf 
needles, five to ten in number, are placed. B, forceps grasping cover of brass cap¬ 
sule. These devices hold capsule and cover while screwing capsule open or closed, 
thus avoiding injury to fingers by repeated contact. C, brass capsule, held by 
strong silk. In this are placeed five, seven or ten needles containing 10 mg. of 
radium sulphate each. D, the capsule is then placed within rubber fountain pen 
reservoir for keeping it clean and in certain instances to prevent soft secondary 
radiations from injuring the superficial tissue when a deeper effect is desired. 
Such an applicator may be placed within the uterus, held in place by packing, for 
twelve to twenty-four hours, depending on the nature of the condition treated and 
the amount of radium used. 

tion and even cancer. Already in certain instances there has been caused 
not only great annoyance from discomfort but actual impairment in 
manual dexterity in performing delicate manipulations, because of per¬ 
sistent local anesthetic effects. 














INJURIES INCIDENTAL TO HANDLING RADIUM 547 

The symptoms caused by handling radium may occur very insidiously 
and consist of blunting of sensibility of the finger-tips, paresthesia such 
as increased sensitiveness to beat and pressure, amounting at times to 
actual pain, and finally to anesthesia of varying degrees. 



A B B C D E 


Fig. 2.—Further Devices for Avoiding Contact of Fingers with Radium. A, shears 
found convenient for cutting sheet lead for use as screens and special applicators. 
B, locking forceps to hold radium needle while it is being threaded with strong 
silk by holding end of silk in small forceps. C, braided silk fish line, very strong 
and best for holding capsules. D, spool of strong crochet silk for holding needles. 
E, spool of ordinary surgical silk—not strong enough. 


The subjective disturbances are out of all proportion to the objective 
findings which include flattening of the natural “ridges” on the affected 
fingers with consequent changes in the characteristic markings of the 
finger prints, thickening of the horny layer of the epidermis with scaling 
in varying degree, failure of the tips of the fingers to resume their normal 
shape after pressure, a sort of pitting, upgrowth of the cuticle at the base 
of and underneath the nails which tend to stand off from the fleshy part 








548 


RADIUM THERAPY 


of the fingers and which become ridged, easily cracked and extremely brittle. 

Various general symptoms such as headache, malaise, weakness, undue 
fatigue, unusual need of sleep, increased excitability, fretfulness, irrita¬ 
bility, disorders of menstruation, attacks of dizziness, etc., have been 

said by Gudzent and 
Halberstaedter to 
be caused by repeated 
and long-continued ex¬ 
posure to radio-active 
substances. Such 
symptoms are, how¬ 
ever, common in many 
people at times and, 
as they cannot he ac¬ 
curately and objectively 
recorded, there is 
doubt if they can be 
definitely proved to be 
due to exposure to 
radium. They may be 
due to close confine¬ 
ment, tiring routine 
and lack of outdoor 
exercise and other 
causes. The exposures 
of some of the cases 
reported were doubt¬ 
less large; some of the 
individuals affected 
were assistants in 
“Fabriks” for manu¬ 
facture of radium ap¬ 
paratus, and some had 
been engaged for years 

during the entire day in work with radio-active substances. It is, there¬ 
fore, probable that certain general symptoms do occur as a result of ex¬ 
posure. 

Changes in the blood of radium workers were observed by Gudzent 
and Halberstaedter. Most striking was the relative and absolute increase 
in lymphocytes from 36 per cent to 63 per cent, average of ten cases 
46.4 per cent; a relative and absolute decrease in neutrophils, average 
50.3 per cent. There was little change in red blood-corpuscles, slight 
diminution in white cells and the hemaglobin was lowered in only two 
cases, 70 per cent and 71 per cent respectively. 



Fig. 3.—Thick-sided Lead Box and Cover to Protect 
Workers from Radium Radiations While Making 
and Applying Applicators. In the lead box are a 
non-corrosive steel needle containing 10 milligrams 
of radium sulphate and a brass capsule in which are 
two similar radium needles. 




INJURIES INCIDENTAL TO HANDLING RADIUM 549 


\ arious methods have been devised for avoiding these injurious ef¬ 
fects. In order that the least possible contact of the fingers with the 
radium may occur, forceps or special vises are used for holding tubes 



A B 


Fig. 4. —Devices for Protection against Radio-active Substances. A. strong lock¬ 
ing needle holders used for grasping radium needle and forcing it into growth. 
Holders made to grasp radium needles at various angles and thus facilitate the 
introduction into the tissue. B, sheet lead pic> inch to hold brass capsule containing 
five to ten radium needles of 10 mg. each. The lead acts to screen radiations 
and thus protect bladder or rectum as case may be when applicator is inserted into 
vagina or rectum respectively. The sharp edges of the lead are filed smooth and 
the applicator is covered with rubber finger cot and dental rubber sheeting to keep 
it clean and to prevent secondary radiations from lead. The rubber sheeting is 
held in place by adhesive plaster. 

and for opening and closing them; special metal boxes have been con¬ 
structed so that the active tubes may be safely stored and kept when not 
actually in use. Special rubber envelopes for containers have been de¬ 
vised in order to avoid wrapping the radium up by hand in sheet rubber 
(Fig. 7). Leaded gloves, fingers, etc., are clumsy and are not readily worn. 













550 


RADIUM THERAPY 


In placing active tubes in special applicators it is important to avoid 
all contact with radium and, as the effects are not apparent at once, as 
when handling very hot objects such as heated glass, but only after a 
period of days or even weeks, it will be difficult to train a worker to avoid 
all contact with the active apparatus. Therefore, in the work of making 
routine applications of radium there should be a rotation in the staff and 
persons affected should be freed at least temporarily from such work. 

In order to avoid general disturbances, the body should be protected 
as far as possible by metal screens in the form of lead boxes or plates 
about the radium; there should be frequent ventilation of workrooms, par¬ 
ticularly if there is radium emanation present, and a change of duty and 
shorter hours; periodic physical examination of those working with radio¬ 
active substances, with special reference to the blood examination, is 
indicated. 

From the above it is evident that marked changes may occur on the 
fingers of those engaged in routine work with radio-active substances. 
These local objective changes consist chiefly of flattening of the char¬ 
acteristic ridges, thickening and scaling of the superficial layers of the 
skin and even atrophy and intractable ulceration. These lesions are 
usually slight compared with the marked subjective symptoms, such as 
paresthesia, anesthesia of varying degree, tenderness, throbbing and even 
pain. The persistence of such effects is noteworthy. 

Various general systemic symptoms and also bjood changes may be 
produced by exposure to radio-active substances. To avoid such local and 
general disturbances special protective and preventive measures have been 
devised and those engaged in routine handling of radio-active substances 
are particularly cautioned. 

Application and Administration of Radio-active Substances .— 
Radium may be used either externally or internally, for research or 
routine therapy. It may be used as a salt when spread evenly over ap¬ 
plicators and retained in position by special varnish or the salt may be 
employed in tubes, needles or in special containers. 

The emanation or radio-active gas evolved from a solution of radium 
has the properties of a gas, that is, diffusion, solubility in liquids, con¬ 
densation, and liquefaction at a certain pressure and temperature. It is 
also radio-active, that is, it ionizes, air, discharges electrical bodies, affects 
photographic plates, passes through bodies opaque to light, and provokes 
phosphorescence in different substances and even in the glass which con¬ 
tains it. Emanation derived from a dilute solution of soluble salt of 
radium, usually the chlorid, may be freed from the admixture of hydrogen 
and oxygen, due to the hydrolysis of water, and reduced to a very small 
volume by Duane’s method of passing it over a heated copper coil or by 
condensing the “impurity” of hydrogen and oxygen by liquid air. Then 
it may be passed by mercury pumps into capillary glass tubes which are 


ACTION OF RADIUM, LOCAL AND GENERAL 551 

sealed off into lengths suitable for various containers. The emanation 
may also be compressed into special containers and used without “purifica¬ 
tion.” It may be set free into special chambers for inhalation or dis¬ 
solved in water for drinking or for injection. 

Radium A, B, C, the so-called “active deposit” from the emanation, 
may be used for external application by various appliances or when de¬ 
posited according to Duane’s method it may be used medicinally by in¬ 
jection, etc. As radium in the form of a salt, such as the sulphate, loses 
half its strength in a little less than 2,000 years, it may be regarded as 
practically constant for therapeutic purposes. The emanation, however, 
loses half of its strength in 3.85 days, that is, it weakens practically one- 
sixth a day; therefore allowance for this must be made in treatment. The 
deposited activity, radium A, B, C, loses half its strength in one hour. 
Because of the technical procedures necessary for purifying the emana¬ 
tion and for obtaining the active deposit and because of the relatively short 
period of their activity, these forms of radium are in less general use ex¬ 
cept in clinics where a physical laboratory is maintained. 

The use of radium emanation, however, has certain practical advan¬ 
tages, particularly in avoiding loss of the radium by theft or accident. 
The solution of radium may be kept carefully locked in a safe while the 
emanation is constantly being formed from it. The emanation may be 
put into containers of various sorts and conveniently sent away by post. 
It should be borne in mind, however, that half the strength is lost in 
3.85 days; therefore, the emanation can he sent only a limited distance. 
The disadvantages of using emanation are that it is constantly losing its 
radio-activity as above indicated and it is, therefore, somewhat more 
difficult to apply very exact dosage, which may be important in certain 
cases. 

Action of Radium, Local and General.—It has been said that radium 
acts merely as the most expensive and efficient form of cautery as yet dis¬ 
covered. On the other hand, it has been claimed that the radiation from 
radium has a marked selective action in destroying pathological tissue 
without affecting normal tissue. Between these extreme views, however, 
a mean should be taken. While it is true that the alpha, beta and gamma 
rays do exert a somewhat selective action, this, however, is only relative, 
the more embryonic and cellular tissue being chiefly altered. By prolong¬ 
ing the exposure, however, even dense fibrous tissue may show changes. 
There is great variation in the effect of radiation upon different growths 
and also on normal tissues. The lymphatic organs are specially sensitive 
and easily destroyed and also the hair follicles, the glands of the skin, 
and the reproductive portions of the ovary and testis. The endothelium 
of the blood-vessels may swell up and cause occlusion of the vessels with 
marked diminution of the blood supply. Cartilage, bone, muscle, con¬ 
nective and nerve tissues, including brain, are very resistant to radiation. 


552 


RADIUM THERAPY 


In many cases it is impossible to predict by histological examination which 
growths will be easily affected and which will prove refractory to the 
action of the rays. Although it has been supposed that the action is 
purely local and direct upon the cells themselves, there may also be an 
indirect, possibly cytolytic, or other “immunity” reaction secondarily 
produced. The destruction of tissues exposed to radium is usually by 
necrobiosis, the nuclei become swollen and vaculated, the nucleoli become 
enlarged and fragmented, the staining characteristics of the tissues are 
altered, and death of the cell ensues. It is believed that the effect of the 
radiations 3 is to produce ionization of the atoms of the different sub¬ 
stances the rays penetrate and that chemical changes follow as a secondary 
result of the ionization. 

After exposure to radio-active substances there is usually a latent 
period of longer or shorter duration before the effects become evident. 
This latent period varies from one or two days to even two or three 
weeks or longer. It depends in most instances upon the strength of the 
source of energy and upon the amount of filtration and protection used. 
In certain instances it may depend upon personal idiosyncrasy. 

The effects of exposure to radio-active substances may be either local 
or general. Local effects on the skin may vary in intensity from erythema 
to vesiculation or ulceration of varying degree and possibly lead to the 
development of cancer. To these dangers the attention of those engaged in 
radium therapy is particularly called. General effects such as sterility, 
changes in the blood, and constitutional disturbances such as nausea and 
vomiting may occur. 4 

Comparison of X-ray and Radium.—Although there are numerous 
physical differences between Roentgen rays and those emitted by radio¬ 
active substances, in certain respects they are analogous. They produce 
similar chemical action on photographic paper or film, they cause fluores¬ 
cence, they penetrate opaque objects, and have the property of ionizing 
the air and so rendering it a conductor of electricity. The similarity be¬ 
tween the physiological action of the Roentgen rays and of radio-active 
substances, particularly if used by like methods, is striking. In general 
it may be said that the local therapeutic effects of unfiltered X-rays pro¬ 
duced by soft tubes and low voltage may be compared with rays from 
radio-active substances if filtered through a very thin sheet of paper or 
aluminum which intercepts merely the alpha rays, that is, unscreened 
rays with very short exposures of a few minutes are comparable in effect 
to weak beta rays of radio-active substances with exposure of from fifteen 


3 Radiations will be the term applied to rays, particles, or electrons derived 
from radio-active substances. 

4 These have been described in considerable detail by Tyzzer and Ordway in 
Diseases of Occupation and Vocational Hygiene, Kober and Hanson, P. Blakiston’s 
Son & Co., 1916. 



COMPARISON OF X-RAY AND RADIUM 


553 


minutes to an hour. Such rays have comparatively little penetration and 
are used in the treatment of superficial lesions of the skin and mucous 
membranes, for it is believed that only the rays absorbed produce physi¬ 
ological changes. It is, therefore, necessary, in order to produce any 
marked effect on deeper tissues, to use screens or filters to check the less 
penetrating rays which would otherwise be absorbed by the superficial 
tissues and cause marked destructive changes there, before the less numer¬ 
ous and more penetrating rays could act on the deeper tissues. When 
using radium it has been shown that screens or filters (lead 2 or 3 milli¬ 
meters thick, brass 1.2 millimeters, or other heavy metals such as silver 
and gold or platinum) allow the penetrating hard beta and gamma rays 
to pass and intercept the alpha and soft beta rays which would otherwise 
be absorbed and cause destructive changes in the superficial tissue. It 
must be remembered in this connection that metals, more particularly 
lead, used as filters for radiations, do give off, in a varying degree, soft 
beta, the so-called secondary rays. As the amount of the more penetrat¬ 
ing rays is only a small proportion of the total activity, less than 5 per 
cent, it is necessary in deep therapy to make the exposures correspondingly 
long. Hours are required, even twenty-four, forty-eight, or longer, for 
deep therapy with heavily screened apparatus, whereas a few minutes to 
an hour are used in the treatment of more superficial lesions with radium. 
Fluorescent dyes, colloidal metals, and other substances have been advo¬ 
cated to “activate” or intensify the action of radiations. They have not 
as yet, however, been proved to be of clinical value. 

In practical radium therapy, radio-active substances are in certain cases 
doubtless preferable to the use of Roentgen rays, particularly when there 
is necessity for the most precise localization, especially within the body 
or in the cavities difficult of access; also when the condition of the patient 
or circumstances demand portability of the therapeutic agent for con¬ 
venience or ease of treatment. The disadvantages of radium are its great 
expense for sufficient doses necessary in some cases, also the possibility 
of loss of the salt by accident or theft. This may, however, be obviated 
by insurance of the radium or by use of the emanation as above indicated, 
but the expense of the latter is increased because of the necessity of re¬ 
taining a physicist and equipping and carrying on a physical laboratory. 
When sufficient clinical experience has been gained in the application 
of the recent advances in the production of highly penetrating homogeneous 
X-rays of great volume by Coolidge and his coworkers, supplemented by 
careful scientific study of the physiological effects, we believe that there 
will be, in the majority of cases, very little difference in the therapeutic 
value of the X-ray and radio-active substances. 

If radium is to be employed as a therapeutic agent, it is important 
not to use X-ray or any form of caustic previously, for the results of ra¬ 
dium therapy under such circumstances are usually very disappointing. 


554 


RADIUM THERAPY 


Medicinal Use of Radium.—The treatment of so-called medical diseases 
by radio-active substances must be considered even at the present time 
to be in the experimental stage. The indications and contra-indications 
are not as yet clear nor have the results been sufficiently definite in many 
instances of supposed cure to judge the real value of the treatment. 

Radium may be administered internally as a therapeutic agent by 
various methods. A soluble salt such as the chlorid or bromid of radium 
may be injected into the body or taken by mouth or used for bathing. 
The emanation, the radio-active gas evolved from a solution of radium, 
is somewhat soluble in water and may thus be used in the same manner 
as the soluble salt. In the form of gas it may also be taken into the lungs 
by various devices—in the small personal respirators, with mouth or 
nose pieces, in cabinets or in bed or in room emanatoria. Patients remain 
for hours in some of these; the resulting carbon dioxid and water vapor 
are removed by soda-lime and sulphuric acid, oxygen is added, and the 
temperature is controlled by coils as in the calorimeter. The active de¬ 
posit radium A, B, C, when deposited on salt, may be administered in a 
manner similar to the soluble salt above indicated. The dosage of the 
various forms of radium taken internally is, at present, very variable, wide 
range having been employed by various workers as below indicated. 

Radio-active substances may be employed in other ways. In the form 
of packs, naturally active material of pitchblende residue or artificially 
activated material is used. It has also been given as baths, the water be¬ 
ing derived from naturally radio-active springs or water to which has 
been added soluble radium salt or emanation. Indeed, it has been claimed 
that the beneficial effects of the waters of certain well-known springs are 
due to the fact that they contain radio-active substances, chiefly emana¬ 
tion. When radium or its products are given by mouth, it is believed 
by von Hoorden that there is greater effect upon the liver, as the emana¬ 
tion reaches the heart through the portal veins and leaves the body almost 
entirely through the lungs within a few hours. When emanation is 
inhaled he considers that the emanation goes more rapidly into the gen¬ 
eral circulation. In the radio-active bath of 200 liters the natural radium 
content varies from 31,000 to 120,000 M. E. (Mache units) or in some 
instances 450,000 M. E. 5 

When water is artificially activated, similar amounts have been used. 
When radium emanation is used for drinking, 1,000 M. E. a day up to 
10,000 or, in certain instances, 90,000 M. E. a day have been given by 
the German school. They usually begin with doses of 330 M. E. three 
times a day and for further treatment proceed to 5,000 or 10,000 M. E. 
three times a day and in individual cases 30,000 to 90,000 M. E. a day. 
The Radium Institute in London, during the year 1914, recommended the 

5 One-thousandth of a milligram (a microgram) of radium solution in equilibrium 
is equivalent to 2,700 M. E. of emanation. 



PHYSIOLOGICAL ACTION OF EMANATION 


555 


drinking of at least % liter of water activated by emanation containing at 
least 1 millicurie per liter (a millicurie being equivalent, according to the 
physicist at this Institute, to 2,160,000 M. E.). This would make the 
dosage vary from 540,000 to 1,080,000 M. E. daily. It is believed at the 
Radium Institute that at least six weeks’ treatment is necessary before 
benefit is noticed. 

When a solution of the soluble salt of radium is used for drinking 
or for subcutaneous injection, the dosage given has varied from 50 to 250 
micrograms. The above indicates the very great variations in the dosage 
which have been employed by different observers. Similar variation is 
seen in the case of emanatorium treatment in which some recommend per 
liter of air 2 to 4 M. E., others begin with the same dose and increase to 
22 M. E. and gradually to 45, in special cases to 110, eventually to 220, 
440, or even 660 M. E. Von Noorden and Falta have given 1,200 M. E. 
per liter. Coutard recommends emanation from 2 to 4 milligrams of 
bromid of radium (without accumulation) in a room of 10 cubic meters. 
He has the patient remain in this room for one and one-half hours. Va¬ 
rious devices are now on the market for furnishing water containing 
emanation. The dose is, in many instances, small and it is important 
that the products of apparatus used in conjunction with radium therapy 
should be carefully analyzed by a competent physicist for the true radium 
content. 

Physiological Action of Emanation—It has been claimed that emana¬ 
tion in many patients increases the gaseous exchange and the respiratory 
quotient. In Basedow’s disease, although the basal exchange is above 
normal, it may be still further increased by emanation. Emanation is 
thought by some to increase sugar metabolism as well as that of albumin 
and purins. The uric acid output is particularly increased by emana¬ 
tion in cases of gout. The influence of emanation on the blood picture 
may be striking; at first there may be hyperleukocytosis and later a 
diminution in white cells. There is a relative increase in mononuclear 
cells. It is also claimed that in certain instances emanation acts as a 
diuretic, and it has been said to exert a stimulating influence on the sex 
glands, particularly in cases of acquired impotence or in tabetics or in 
senility. Cases are cited of the return of menstruation after the meno¬ 
pause and also in certain instances of amenorrhea. It has also been as¬ 
serted that radio-active matter modifies the phenomena of inflammation 
and stimulates the action of the various ferments—such as the pancreatic, 
peptic, and lactic acid and the autolytic ferments in the tissues. 

Attention has been called to such symptoms as dizziness, pressure in 
the head, weakness, albuminuria, and hemorrhages following large doses 
and experimentally it has been found that serious complications may re¬ 
sult in animals. With large doses also there may be- marked changes in 
the metabolism and in the blood picture. Such claims have not been 


556 


RADIUM THERAPY 


generally confirmed. It should be realized that the real value of the 
internal or medicinal use of radium and its products is at present doubt¬ 
ful, and because of the possibility of harmful effects it is advisable to 
begin with small doses and to he conservative in our estimation of the 
results. 


THERAPEUTIC EFFECTS OF RADIO-ACTIVE SUBSTANCES 

Arthritis Deformans (Chronic Rheumatism ).—The types with exuda¬ 
tion are said to he more favorable than the dry forms. His has reported 
cases with striking improvement in the general condition. At the Radium 
Institute in London, Pinch reports extremely favorable results; some¬ 
times, as he said, the results are remarkable. At this Institute, 250 c.c. 
of emanation solution of a strength not less than 1 millicurie per liter 
up to 2 millicuries per liter are given to patients suffering from this 
obstinate, painful, and crippling disease. Pinch says that it is difficult 
to predict with certainty the degree of improvement likely to occur in 
any particular case but that the cases which appear to derive most benefit 
are those in which the disease is of relatively short duration and the 
changes are periarticular in type and multi-articular in distribution. The 
age of the patient also exerts some influence, those under forty responding 
more quickly to the action of emanation. Little or no improvement can 
be looked for in instances when cartilaginous or osseous changes are pre¬ 
dominant. When limitation is due to periarticular fibrous thickening, 
considerable increase of mobility often follows and enables patients to 
perform actions such as feeding themselves, brushing their hair, shaving, 
etc., which they may have been powerless to do for some months or even 
years. Muscular and articular pains are lessened or disappear, grating of 
the joints on movement is not so marked, muscles may regain much of 
their lost tone, and the patient’s general health may be much improved. 
The treatment must, however, be persisted in for quite a long time, at 
least six weeks, before any change is noted. McCrudden believes that 
the creatinin metabolism may be influenced by radium emanation water. 

Acute Articular Rheumatism.—In the majority of cases treated by 
von Noorden, it is claimed that emanatorium treatment acts as well as 
salicylates, the local symptoms subsiding in a few days. Salicylates were 
used in conjunction with emanation, however, in certain cases. The treat¬ 
ment was from two hours to over night and the doses 220 to 1,200 M. E. 
Von Yoorden and Falta believe emanation is specially valuable in cases 
which do not stand salicylates well. 

Chronic Arthritis.—In arthritis secondary to acute general infections 
or from a focus in the tonsils, teeth, etc., results are doubtful. 


EFFECTS OF RADIO-ACTIVE SUBSTANCES 557 

Gonorrheal Arthritis.—The results are not favorable although occa¬ 
sionally improvement is obtained on injecting solutions of soluble radium 
salt in the vicinity of the joints. 

Tuberculosis of Joints.—Results are not favorable. 

Gout.—His reports a large series of cases of gout treated by emana¬ 
tion; the uric acid content of the blood is said to be greatly lessened 
although there is not a complete parallel in the blood content and the 



A 


Fig. 5A.—A Blood Smear from a Patient with Myelogenous Leukemia, Taken 
before Radium Treatment. White blood count 500,000; large numbers of myelo¬ 
cytes and myeloblasts are shown. 

clinical changes. Some cases show improvement in the general condition, 
subsidence of joint swelling without marked diminution of uric acid in 
the blood. Other cases with gouty nodes, even in periods of the most 
frequent attacks, show no abnormal amount of uric acid in the blood. 
Many cases under treatment by radium emanation show disappearance of 
the tophi in the ear. Gudzent reported one hundred cases of gout, in some 
of which he secured still further improvement by injection of a dilute 
solution of radium salt. In the beginning of treatment there may be 
temporarily an increase in pain as the result of reaction. Emanation may 
be used both by drinking and by inhalation. Radium should not replace 




558 


RADIUM THERAPY 


treatment by die! and other common aids in the treatment of gout such as 
hygienic measures, colchicum and related drugs. 

Leukemia.—Von Noorden and Falta did not obtain any favorable 
results by emanatorium treatment in leukemia but only produced an 
increase in the blood count. The writers, however, by surface applica¬ 
tions of radium over the enlarged spleen have, in a series of cases, ob¬ 
served a most remarkable improvement and striking changes in the size 



B 

Fig. 5B.—A Blood Smear from a Patient with Myelogenous Leukemia, Taken 
during the Course of Radium Treatment. There is a marked diminution in the 
number of white blood-cells, 74,000; the diminution is chiefly in the myeloblasts 
and myelocytes with a relative increase in the polymorphonuclear leukocytes. 


of the spleen, the blood picture, and the general condition of the patient. 
In the course of a few weeks or, in stubborn cases, in three or four months 
after treatment by the surface application of radium, according to the 
method described in this article, a spleen which filled almost the entire 
abdomen, extending well to the right of the median line and into the 
pelvis and causing marked pressure symptoms, has been reduced to normal 
dimensions so that it was not palpable below the costal margin. Blood 
with white counts of from 500,000 to 700,000 became 6,000 to 8,000. 
The immature forms of white cells—the myeloblasts, myelocytes—are es- 




EFFECTS OF RADIO-ACTIVE SUBSTANCES 


559 


pecially affected. The hemoglobin increased from 40 to 70 or even to 80 
or 90 per cent. The red blood-corpuscles increased from 2,000,000 and 
2,500,000 to 4,000,000 and 5,000,000; indeed, the blood picture often 
approximated normal. A pale, emaciated, anxious individual with promi¬ 
nent bony framework, stooping shoulders and enormously enlarged abdo¬ 
men, usually loses the anxious expression, becomes plump, the abdomen 
returns to normal size, the color and strength improves so that the patient 



C 

Fig. 5C.—A Blood Smear from a Patient with Myelogenous Leukemia, Taken 
after the Course of Radium Treatment. The myelocytes have entireely dis¬ 
appeared, the white count is 5,800; considerable variation in size and shape of the 
red cells persists, however. 

may feel entirely well. The pathological condition, however, sooner or later 
is apt to relapse gradually and the response is less prompt in subsequent 
series of radium treatments, although cases have been kept in good condi¬ 
tion for a period of one to four years by occasionally repeating the radium 
treatment. Numerous cases, however, have died of intercurrent infections 
or have succumbed to the original disease. Although these results in the 
radium treatment of leukemia are most striking in the chronic myelogenous 
variety, in certain cases of lymphatic leukemia results are almost equally 
good. It must be understood, however, that the results should be regarded 
at the present time merely in the light of palliation and not as cures. 




560 


RADIUM THERAPY 


It is hoped, however, that future research will at least increase the dura¬ 
tion of these remissions. Although the treatment must not be considered 
at the present time as curative, from the results obtained it is the best 
form of treatment now at our disposal. Certain of the cases which re¬ 
spond promptly to radium applications over the spleen had previously 
proved entirely refractory to prolonged X-ray and to benzol treatment. 

It is to be noted, however, that in the surface applications of radium 
above described the results were obtained without radiating the long bones; 
in fact, in one instance in which the long bones were radiated there was, 
apparently, an increase rather than a diminution in the white cells. It 
is also believed that the results are more prompt by the radium treatment 
than by X-ray, as hitherto employed, and no case has been accompanied 
by severe toxic symptoms, although there is a marked increase in the 
endogenous purin metabolism. On a purin-free diet, uric acid, urea and 
total nitrogen in the urine are markedly increased. 

Miscellaneous Conditions.—In a few cases of croupous pneumonia 
it is claimed that the temperature began to fall earlier than usual and 
by lysis and that the dissolution of the exudate was strikingly rapid. 
The symptoms, such as difficulty in breathing, were markedly relieved in 
the emanatorium in which 100 M. E. of emanation per liter was used. 
In certain instances the patients remained in the emanatorium over night. 
In diabetes mellitus the effect upon the sugar metabolism is not constant 
but the emanation therapy is said to affect favorably diabetic neuritis. In 
certain cases of neuralgia, neuritis, and sciatica, it has been claimed that 
the condition has been benefited. Claims have also been made for favor¬ 
able therapeutic effects in the case of arteriosclerosis, certain kidney dis¬ 
eases and even in tabes dorsalis; in the latter instance more particularly 
in relieving the so-called lightning pains. In some cases of syphilis in 
which a positive Wassermann persisted in spite of active and prolonged 
treatment, intravenous injection of from fifty to two hundred and fifty 
micrograms of radium chlorid solution at intervals of a few days and 
later once a week resulted in the reaction becoming negative in certain 
instances. It would seem, however, that there has been much exaggeration 
of the value of radium in many of these chronic conditions. 

The indications and contra-indications for the internal use of radium 
are vague. The value of the medical uses of radium has been greatly 
exaggerated and reports are confusing. The great variations in dosage 
add to this. There seems no question, however, that benefit has been de¬ 
rived in certain forms of gout and chronic rheumatism and neuritis. The 
effect upon the hematopoietic tissues, either stimulative or destructive, 
must, however, be borne in mind. Improvement has also been reported 
in cases of pernicious anemia, erythrocythemia and in hypertension. In 
the latter the blood-pressure is said to have been reduced to normal and 
the subjective symptoms are said to have disappeared. 


EFFECTS OF RADIO-ACTIVE SUBSTANCES 


561 


Internal therapy by radio-active substances is still too recent and 
poorly controlled to express a very decisive opinion regarding its value. 
The duration of favorable results reported is not known in most in¬ 
stances. There is need of more control cases, and of a large number of 
cases worked up in detail treated by different methods and followed to 
end results before certain conclusions may be drawn. 

External and Surgical Use of Radium.—The value of the so-called 
surgical use of radium is much more definitely established than its medic¬ 
inal use. Even the most conservative and careful clinicians who have had 
any extended personal experience with adequate amounts of radium rec¬ 
ognize its value and limitations when used in certain “surgical” diseases. 
In a large proportion of this class of cases, surgery is undoubtedly pref¬ 
erable and radiations, if employed at all, should be used not to replace 
but, in many instances, to supplement surgical procedures. We believe 
that many of the extraordinary claims have prevented a proper estima¬ 
tion of the true value of radium therapy, both by the profession and the 
laity. This has been due to the fact that the exceptional cases in which 
there has been great relief, or even cure, have been reported as if they 
were the rule. In describing the limitations of radium therapy, the fact 
must be taken into account that there are from time to time very ex¬ 
ceptional cases, particularly of malignant tumors, some of which have re¬ 
peatedly recurred after numerous operations, and also cases that have been 
entirely inoperable which have apparently yielded to radium therapy. 
While the careless or the overenthusiastic physician has described these 
cases as if they were the rule, yet it is by studying them most carefully 
and becoming acquainted with as many of the factors involved as pos¬ 
sible, that we may hope that these now exceptional and unusual cases may 
become more and more frequent. It is thus, also, that we may expect 
truly to advance the progress of radium therapy. In describing condi¬ 
tions in which radium therapy has been used, it is difficult to follow a 
systematic or logical arrangement, either from the point of view of path¬ 
ology, etiology, or anatomy. Therefore, both anatomical and pathological 
arrangement will be made use of. 

Methods of Application.—It is almost impossible to give detailed rules 
for the application of radiations. The source of radiation for therapeutic 
use should be not only physically but physiologically standardized under 
the exact conditions in which it is to be employed. The duration, amount 
of radio-active element, filtration, distance and, in certain instances, the 
individual variation of the subject of the experiment must be considered. 
The great variation in the reaction of different tumors to the radiation 
has been pointed out by Werner. In practice it has been found of the 
utmost importance to use the method of “physiological standardization,” 
not only for becoming familiar with the various changes produced in 
animals, but in the tissues of man subjected to radiations. For example, 


562 


RADIUM THERAPY 


in order to apply radium intelligently for therapeutic purposes, it is nec¬ 
essary to establish a so-called “erythema dose,” that is, to determine the 
tolerance of the skin to the various radiations under the conditions 
employed. 

The degree of the acute reaction following the exposure is very variable 
depending upon several factors, namely, the intensity and quality of the 
radiation, the duration of the exposure, the part of the body exposed, and 
the individual sensitiveness or tolerance. Gocht claims that there is no 
special idiosyncrasy as was at one time believed. The intensity and quality 
of the rays depend on the amount of radio-active substance, the distance 
it is from the patient and the filtration employed. The effects depend 
on the rays absorbed by the tissue. The therapeutic indications and effects 
of the X-rays and radio-active substances are almost identical when em¬ 
ployed by similar methods. 

Numerous refinements of the technic of radium application have been 
suggested, and while some of these may facilitate the more exact fixation 
of the radium to the area under treatment, just as good results may he 
obtained by simpler applicators, if due care is taken. For the treatment 
of lesions about the face or mouth, molds of dental wax may be made 
in which the radium is embedded. In some clinics where emanations are 
used, capillary glass tubes or “seeds” containing minute quantities of 
this form of radium are buried in the diseased tissue and left there. Since 
the introduction of needles containing radium element, however, the same 
results may be obtained by inserting the metal needle and withdrawing it 
by a thread attached to the eye of the needle, after the desired length of 
exposure. 

Unusual technical methods such as having the radium rotated by a 
clocklike mechanism so as to diffuse the rays, on the theory of more even 
distribution, do not seem to offer any practical advantage in treatment. 

The strength of radium depends upon the amount of radium element 
present. Therefore, in reporting cases the dosage should be accurately 
stated in milligrams of radium or millicuries of radium emanation, per 
hour, per unit area. A millicurie is the quantity of emanation that fur¬ 
nishes the same penetrating radiation that 1 milligram of radium ele¬ 
ment produces. The dose employed in the external and the so-called sur¬ 
gical use of radium usually varies from 50 to 200 milligrams; in certain 
instances 1 or 2 grams have been used. The smaller doses are employed 
chiefly in superficial skin lesions, the larger for large growths deeply 
situated. 

Tubes, needles, and surface applicators containing radium are used 
on patients according to the following general rules, to which, however, 
there are many exceptions. These rules indicate only single applications 
and can give no idea of the total number of applications or of the time 
elapsing between them. The number of applications varies greatly with 


GENERAL RULES FOR APPLICATION OF RADIUM 563 


the variety and size and extent of the lesion and the intervals are, in 
most instances, from four to six weeks, although, in certain cases, ap¬ 
plications are made every day or two for a week and then, if necessary, 
repeated at the regular four to six weeks’ interval. The most obvious im¬ 
provement usually occurs after the first or second application, which 
should, therefore, be of sufficient intensity to produce the best results. 
Repeated ineffectual applications at too frequent intervals may produce 
actually harmful destructive effects. Small superficial lesions may require 
only a single application of a half hour to one hour’s duration. The time 
of application depends not only on the strength of the applicators, as above 
indicated, hut also on the size and nature of the lesion, the area to be 
covered and the sensitiveness of the patient’s skin. Certain technical de¬ 
tails of application are illustrated in the accompanying illustrations 
(Figs. 1, 2, 4, 6 and 7). 


GENERAL RULES FOR APPLICATION OF RADIUM 

(The following rules apply when an average of one hundred milligrams 
of radium element or its equivalent emanation are used.) 

1. Effects on Pathological Processes Beneath Intact Skin. —Surface 
application— screening or filtration, 2 to 3 millimeters of lead or equiva¬ 
lent; protection from secondary radiations, gauze or paper, wood, distance, 
and rubber; exposure, four to six hours or less. 

2. Superficial Skin Lesions. —Such as keratoses, small growths, etc. 
Screening, none or 0.1 to 0.5 millimeters of aluminum or lead; protec¬ 
tion against secondary radiation, none or rubber cover to keep applicator 
clean, adjacent normal skin carefully protected by a shield of 1 to 2 
millimeters of lead, gauze and rubber; exposure, ten minutes to two hours. 

3. Deep Skin Lesions with Ulceration.— Screening, none, or rubber 
cover for keeping applicator clean; protection of adjacent tissue as in 
No. 2; exposure, two to four hours. Note if lesion is extremely deep or 
very extensive screening, 1 to 3 millimeters of brass or lead and rubber; 
exposure, four to twelve hours or even longer. 

4. Lesions of Mucous Membranes when Superficial.— Same as No. 2 
except exposure of one to two hours. 

5. Lesions of Mucous Membranes when Deep and Growths Beneath 
Mucous Membrane. —Same as No. 3 except exposure twelve to twenty- 
four and forty-eight hours’ duration and in exceptional instances somewhat 
longer. 

6. Introduction of Radium within Growths.— (a) For deep effect, 
tubes with screening of % to 1 millimeter of silver or platinum. Expo¬ 
sure, four to forty-eight hours, depending upon size and nature of tumor; 
average, twelve to twenty-four hours. ( h ) For local destructive effect, 


564 


RADIUM THERAPY 


unfiltered tubes, one to two hours up to twelve hours, length of time 
depending upon size of growth and reaction desired. Unfiltered needles 
(10 milligrams each) ; exposure for three hours usually causes necrosis 
without liquefaction and is a most useful method when the needles are 
evenly placed. Capillary glass tubes containing 2 millicuries of emana¬ 
tion, inserted into the pathological tissues by means of a trochar, are 
allowed to remain, the emanation undergoing slow decay and the glass 
tubes becoming incapsulated by fibrous tissue. 

Further Details of Application. —For deep effects, when 2 to 3 milli¬ 
meters of lead or equivalent are used for filtration, the skin, if intact, is 
protected from the action of the secondary, less penetrating rays by fifteen 
to twenty layers of gauze, paper, or by distance. In practice, radium appli¬ 
cators are wrapped in a thin sheet of rubber to prevent soiling, the rubber 
containers being changed with each patient. In order to fasten the radium 
in place and to secure exact apposition which is so necessary for successful 
results, double-coated adhesive plaster, such as is used in the Wickham and 
Degrais clinic in Paris, has recently been advocated by Tousey and is of 
great technical aid in radium therapy. Supporting bandages, especially 
of the four-tail variety, are useful in relieving the tension on adhesive 
plaster and holding the radium pack in place. Satisfactory sterilization 
of tubes and needles is secured by soaking them in full strength lysol or 
carbolic acid, then washing them off in alcohol and putting them in boric 
acid solution until used. For cleansing, Clissold recommends soaking the 
tubes and needles in equal parts of ammonia and peroxid; this quickly 
removes the dried blood or the dull appearance; then transferring to 
alcohol and to ether, which rapidly dries the tubes and needles before they 
are put away. We have found this method of great assistance. 

Protection .—In treating superficial lesions, particularly small lesions 
of the skin, by radium, it is necessary to use a sheet or mask of lead 1 
millimeter or more in thickness; with gauze or paper beneath it, or a coat¬ 
ing of rubber with a hole cut in the shield slightly smaller than the lesion 
to be treated. A harness or card punch is more convenient than a knife 
for cutting the opening in the sheet lead. Through the opening, the lesion 
may now be exposed to radium and the adjacent healthy skin thus 
protected. 

Cross-fire .—The principle of the so-called “cross-fire” is important 
for successful application of radium to large growths or to deep-seated 
lesions. The method was first described by Dominici and has since been 
elaborated by others, notably in the treatment of uterine fibroids by X-rays 
in the Freiburg clinic. The aim is to concentrate as much of the action 
of the rays as possible in the deep-seated lesion, with the least possible 
injury to the overlying skin. This, may be accomplished by employing 
small tubes of radium scattered throughout the tumor mass or by surface 


GENERAL RULES FOR APPLICATION OF RADIUM 565 



Fjg _Equipment for Treating Small Superficial Lesion of the Skin. A, piece 

of rubber motor cycle inner tube, to be fastened to, and to prevent secondary soft 
beta radiations from lead protecting screen, which protects healthy skin adjacent 
to small lesion. B, lead protecting screen i/ 16 or % 6 inch thick. Hole cut in this 
is slightly smaller than lesion to be treated. C, rubber held to lead by adhesive 
plaster which also protects edges of lead shield. D, brass capsule containing radium 
needles held over opening in protecting shield. Usually for such an application 
in superficial lesions radium needles are used instead of brass capsules. E, brass 
capsules of different sizes to contain varying number of radium needles. F. non- 
corrosive steel needles containing 8 to 10 mg. of radium sulphate, usually 10 mg. 














566 


RADIUM THERAPY 


applications of heavily screened radium to a large number of areas on 
the skin so that each area will not be exposed too long or too intensely, a 
result which would follow the application of the radium to a single area 
for the time necessary to produce the desired result on the underlying 
lesion. By this cross-fire method enormous doses may he applied to the 
deep lesion. 



A B C 


Fig. 7.—Applicator for Treating Deep-seated Lesion by Surface Application 

THROUGH THE SKIN WHEN THE LATTER Is INTACT AND DEEP BUT NOT SURFACE 
Effect Is Desired. A, three brass capsules containing respectively four, two, and 
four radium needles in a lead box % 6 or % 6 inches thick. B, the latter is slipped 
into an envelop made of the inner tube of a motor cycle tire. The cover of this 
lead box and the flap of the rubber envelop are held by adhesive plaster. C, gauze 
bandage is folded into twenty or thirty layers and placed over the applicator for 
comfort of the patient and to aid in avoiding injury to the skin from secondary 
radiations from the lead. This effect may also be secured by filtration by distance 
by means of a wooden block, but gauze and felt, etc., are more comfortable. 

Deep Therapy. —Cross-fire as above described, in order to he success¬ 
ful on deep-seated lesions beneath the skin, requires strong filtration of 
the rays. The technic of the so-called deep therapy, which should he 
used when the greatest effect is desired on deep-lying disease processes, 
may be illustrated by the striking result of radium when applied in the 
proper manner to the surface over the enlarged spleen in cases of myel¬ 
ogenous leukemia. For this the following details have been elaborated. 
The area of the enlarged spleen is carefully and plainly marked out with 









GENERAL RULES FOR APPLICATION OF RADIUM 567 


■a skin-pencil or grease paint, the outline being indicated by percussion 
and palpation. Then the various landmarks such as the costal margins, 
anterior superior spine of the ilium, the symphysis pubis and the umbilicus 
are also marked. The patient is photographed in an erect position in both 
frontal and lateral views. A series of small squares, about 3 centimeters 
in diameter when the radium applicator is 2 centimeters in diameter, are 
marked over the area of enlarged spleen. It is important not to have the 
successive application areas too near together or the skin between will be 
burned by the double dose. The squares are numbered serially. Tracings 
are now made on tracing cloth which serves as a chart for guidance in 
following the series of treatments. A swathe of thin cotton is carefully 
fitted to the abdomen and the outline of the enlarged spleen, bony land¬ 
marks and small squares is traced upon it. This swathe is left in place 
during the single series of treatments. The purpose of the swathe is to 
avoid the irritation of repeatedly applying and removing the adhesive 
plaster which holds the radium applicator in place. It has been found 
that the area which is being or has been radiated is particularly sensitive to 
injury from the repeated application and removing of adhesive plaster. 
The added irritation may induce vesiculation or even superficial ulcera¬ 
tion of the skin. 

With the chart as a guide, the radium applicator, screened with 
2 to 3 millimeters of lead or brass and fifteen to twenty thicknesses 
of filter paper and wrapped in gauze is now applied to the squares in the 
order indicated. It is necessary also to add at least as much filtration and 
protection to the external side of the applicator, for the patient may in¬ 
advertently bring some other part of the body in contact with the ap¬ 
plicator during sleep and serious burns may result. In the second series 
of treatments, which is usually necessary in four to six weeks, applicators 
are similarly applied. A new swathe and tracing should be made at 
each series. The duration of the application in each area with 50 to 
100 milligrams of radium is four to six hours. An amount of radium 
as small as 25 milligrams has reduced a greatly enlarged spleen to normal 
size and caused the characteristic improvement in the blood and general 
condition of the patient, but the time required is longer and the applica¬ 
tions must be more numerous. 

The importance of the distance of the radium from the skin is well 
shown in the illustration of Burnam. He compares a tube 1 millimeter 
away from the skin and applied for one minute with the same tube 1 inch 
away, that is, 25 millimeters, which would require 25 times 25 or 625 
minutes to produce the same effect. By increasing the distance, however, 
the difference in intensity becomes less for parts below the surface of 
the skin, but it would be necessary to increase greatly the duration of ap¬ 
plication, as above indicated, or the amount of radium, if radiation at a 
distance were employed for filtration. 


568 


RADIUM THERAPY 


For deep therapy in the natural orifices and cavities of the body, 
radium applicators are protected by rubber covering in order to prevent 
the more local effect of the secondary rays as well as for keeping the ap¬ 
plicators clean. Such treatment may be applied at one sitting or inter¬ 
mittently within a few days. There should then be an interval of from 
four to six weeks during which the patient should be observed and the 
radiated area cared for by surgical cleanliness. It should be noted that, 
as a rule, the maximum beneficial effect is obtained with the first treat¬ 
ment, which should be the theoretical optimum dosage. 

External Use of Radio-active Substances 



Diseases of the Skin.—In the field of dermatology radium therapy 
has been most extensively used and is a most important therapeutic agent. 

Rodent Ulcers .—These ulcers 
are most amenable to radium 
therapy, particularly the more 
superficial forms which have less 
induration and do not involve 
bone or cartilage. Results of 
radium are much better in cases 
which have not been previously 
subjected to ineffectual and mis¬ 
applied doses of X-ray or to 
caustics, solid carbon dioxid, 
ionization, etc. Extensive rodent 
ulcers, involving bone and carti¬ 
lage, with hard brawny edges, are 
very intractable to radium 
therapy, but in a few instances in 
which large doses have been used 
and particularly when combined 
with very careful cleansing and 
dressing of the area and by allow¬ 
ing a sufficiently long interval to 
elapse between the intensive 
treatments, the results of a few 
years ago have been greatly im¬ 
proved. In some cases extensive 
Fig. 8.—Epithelioma of Right Ear. (From operation, even when the entire 
Simpson, C. V. Mosby Co.) process cannot be removed, is of 

value when the operative wound 
is left open, sometimes for many months, as advocated by Greenough. so 
that the first sign of recurrence may be observed and radiated. If skin flaps 



GENERAL RULES FOR APPLICATION OF RADIUM 569 



or other forms of operation are attempted to close the wound, deep recur¬ 
rences are thus obscured and cannot be treated in time. The superficial 
lesions treated by radium require from one-half to a few hours’ exposure, 
while the deep lesions require twelve or eighteen hours or more. When 
the ulcers affect mucous membranes the results are less favorable. 

Epitheliomata, —In some epitheliomata of the skin the results of 
radium therapy are cura¬ 
tive. In the fleshy (basal 
cell) type of carcinoma, 
called by the French 
“carcinome bourgeonnant,” 
the results are remarkable. 

Large growths “melt away” 
under the influence of 
radiations. The success of 
this treatment depends 
largely on the careful and 
frequent cleansing of the 
lesion between the series of 
treatments. 

Epidermoid Carcino¬ 
mata, —As these growths are 
apt to metastasize early it 
is unwise to attempt their 
treatment by radiation. 

There should be prompt and 
complete excision unless the 
location or stage of the dis¬ 
ease contra-indicates. In 
cases which are inoperable 
because of their extent or 
in those which have recurred 
after operation, the results 
are rarely, if ever, curative, Fig - "--Patient in Fig. 8 after Radium 

although occasionally radia- Treatmknt ' ' rrom Simpson ’ C ' V ' Mosby Co -> 
tion may be of palliative value. 

Roentgen Ray Lesions.—Roentgen ray lesions of the skin, such as 
fissures, keratoses and early epithelioma, are cured or greatly benefited 
by the application of radium. Deeper lesions, however, demand excision 
or amputation. 

Papillomata, Verrucce, and Keratoses. —When keratoses are present 
the results are much more rapid if the heaped-up horny material is re¬ 
moved by salicylic acid 10 to 20 per cent in flexible collodion. The acid 
is thus held circumscribed and may be left in place for twenty-four hours. 




570 


RADIUM THERAPY 



Fig. 10.—Keloid of Back of Neck. 
Recurrence after Surgical Re¬ 
moval. Patient referred by Bayard 
Holmes. (From Simpson, C. V. 
Mosby Co.) 


On removing the collodion the remaining papillomata or verrucae usually 
respond quickly to radium therapy in one or two treatments. 

Keloids. —Excellent results are 
usually obtained in keloids following 
wounds, operative or otherwise, or as 
the result of burns. The anesthetic 
effect in painful keloids may be marked. 
Treatment should not be too intense and 
must be continued over a considerable 
period, usually for months. 

Contractures, War Injuries .— 
Radium has been used successfully in 
the after-treatment of old war injuries, 
such as painful scars and fibrous 
adhesions in joints and about tendons. 
Except when there is extensive and deep 
scarring, as in the thigh where fairly 
large doses are required, just as good 
results are obtained by smaller and 
more frequently repeated doses. 

Lupus Vulgaris. —The results in 
some deep-seated cases treated by radium are good. Very short exposures 
are employed and great care is necessary. Finsen light, however, is 

undoubtedly best for the routine treat¬ 
ment of lupus vulgaris. 

Lupus Erythematosus. —The results 
of radiations are variable but occasion¬ 
ally may be satisfactory, particularly 
in obstinate cases. 

Lichen Planus. —Patches of this 
condition usually yield to radiations in 
one or two treatments and there may 
be no recurrence. 

Pruritus. —Short unscreened ex¬ 
posures may produce marked relief of 
itching. The results are particularly 
good, according to Pinch, if the condi¬ 
tion is associated with definite lesions 
such as leukoplakia or hyperkeratoses, 
but not so hopeful if the condition is a 
neurosis. 

Angioneurotic Edema. —Cases of this condition are reported in which 
considerable benefit and even cure resulted from the use of radiation. 
Nevi and Angiomata* —The value of radiations in the treatment of 



Fig. 11. —Patient in Fig. 10 after 
Radium Treatment. (From Simp¬ 
son, C. V. Mosby Co.) 








GENERAL RULES FOR APPLICATION OF RADIUM 571 


Fig. 12.—Lupus Vulgaris of Right 
Cheek in Girl Aged 13. (Taken 
from Radium Therapy, by Frank 
Edward Simpson, C. V. Mosby Co., 
1922.) 

In a series of twenty-four cases 


nevi is variable. Treatment must usually be prolonged for months in the 
most careful manner. In superficial nevi more can be expected if blanch¬ 
ing of the tissue is accomplished by 
gentle pressure. The fleshy cavernous 
nevi in many instances do well under 
radiation, although, if pulsating, the 
results are more successful if the blood¬ 
vessel is previously ligated. In many 
cases the treatment must be extended 
over a long period. 

Miscellaneous Diseases of Skin .— 

Favorable results of radiation have also 
been reported in the following condi¬ 
tions: sycosis, favus, hypertrichosis, 
alopecia areata, tinea tonsurans, hyperi- 
drosis, seborrhea, acne rosacea, comedo, 
psoriasis, and chronic eczema. 

Brain. —There is undoubtedly a 
limited field for the use of radium in 
conjunction with surgery in the treat¬ 
ment of selected cases of brain tumor, 
of brain tumor thus treated, Frazier reports three in which clinical evidence 
offers indisputable proof that radium 
emanations arrested the growth of the 
tumors, and in all probability destroyed 
them. The cases cited have remained 
well for six, seven, and eight years, 
respectively. 

Diseases of the Eye .—Carcinoma of 
the eyelid. —Carcinoma of the lid, even 
the epidermoid variety, usually responds 
in a remarkable manner to radiations 
and because of the possibility of exact 
apposition of radium it is preferable 
to any other form of treatment. The 
result of radium therapy is usually 
curative and the unsightly deformity 
and secondary conjunctivitis and its 
possible sequelae are avoided. The Fig. 13.—Patient in Fig. 12 after 
lid remains flexible and smooth and Radium Treatment. (From Simp- 
there is practically no loss of tissue, son ’ C ‘ V * Mosby Co,) 
except at the exact site of the growth. The cosmetic effect is good. 

Opacities of the Cornea and Lens. —Improvement has been reported 




572 


RADIUM THERAPY 



14 15 


Fig. 14. —Cavernous Angioma of Forehead. Photograph taken March, 1918. (From 

Simpson, C. V. Mosby Co.) 

Fig. 15. —Patient in Fig. 14 after Radium Treatment. Photograph taken Septem¬ 
ber, 1918. (From Simpson, C. V. Mosby Co.) 



16 17 


Fig. 16. —Pigmented Hairy Nevus of Left Eyebrow and Forehead. (From Simpson, 

C. V. Mosby Co.) 

Fig. 17. —Patient in Fig. 1(> after Radium Treatment. (From Simpson C. V. 

Mosby Co.) 













GENERAL RULES FOR APPLICATION OF RADIUM 573 

in cases of opacity of the cornea and lens, but more experience is necessary 
before definite conclusions can be drawn. 

Diseases of Mouth, Nose, Throat, and Ear .—Tuberculosis and new 
growths in the mouth, nose and throat are usually resistant to radium 
therapy. In certain instances sarcoma , even if of large size, may dis¬ 
appear but recurrence is usual. If operable, such cases should receive 
surgical treatment. Occasionally new growths of the tonsils may respond 
quickly to radium therapy even when the glands of the neck are involved. 
Such growths have usually recurred. The results are better if the tubes 
or needles of radium are inserted directly into the growth. In tuber¬ 
culosis and carcinoma of the larynx , radium therapy may give relief but 
the benefit is only temporary. The exact apposition of radium, as well 
as the safety of the patient, is best secured by preliminary tracheotomy. 
In certain instances in which the growth is small and localized, particularly 
in the case of papillomata , good results have been obtained by the use 
of radium. In carcinoma of the esophagus, radium application may cause 
temporary improvement. 

Leukoplakia of the buccal mucous membrane reacts variably to ra¬ 
dium. In some cases a lesion quickly disappears but it is apt to recur. 
In other instances it is refractory to radiation. Leukoplakia is often 
followed by carcinoma particularly when the origin appears to be 
syphilitic. 

In carcinoma of the tongue the results of radium therapy are not 
usually good and the treatment may be attended by added suffering. In 
certain instances, however, the burying of strong tubes of radium in the 
growths of the tongue has given more favorable results. In one instance, 
a circumscribed growth of border-line malignancy with deep papillary 
projections in a woman considerably past middle age, a tube of radium 
was buried in the growth. The latter completely disappeared and there 
was no recurrence. In another case of proved carcinoma of the tongue, 
after incomplete local excision, the residue was treated by radium and there 
has been no recurrence for seven years. 

In the nasopharynx and in the accessory sinuses in exceptional cases, 
remarkable results may be secured in inoperable or recurrent sarcoma. 
In carcinoma, however, in these regions results have not been satisfactory. 
In the majority of cases epithelial growths on the lip are regarded as 
strictly surgical and this is, doubtless, the safer procedure. The der¬ 
matologist, however, recognizes two types of epithelial lesion of the lip; 
the circumscribed superficial type with slight or marked keratoses readily 
responds to radium. The deeper type, even in the very early stages, should 
be treated by radical excision. 

Carcinoma or keratosis of the ear , if involving the cartilage, may 
prove very resistant to radium treatment and may also be very painful. 
The results are variable depending upon the size and extent of the growth. 


574 


RADIUM THERAPY 


In tuberculosis of the ear improvement is usual although the condition 
is obstinate. It has been claimed that small doses of radium have caused 
marked improvement in cases of otosclerosis, that the hearing and also 
such symptoms as tinnitus have improved. Other than the improvement 
that may follow from the encouragement that something is being done, we 
have seen no such favorable results. 

Pathological Conditions of Glands. —In lymphoma and Hodgkin s 
disease the involved glands may be reduced in size by radiation and in cer¬ 
tain instances the disease seems to 
have been restrained. Cures are very 
doubtful and recurrence is usual. 
Kelly and Burnam, however, report 
65 per cent of twenty-five cases of 
lymphosarcoma treated by radium as 
apparently cured and believe that in 
this disease radium should be used, 
even in the early stages, in preference 
to surgery. In metastatic carcinoma 
of the cervical glands, the swelling 
may be reduced in size, painful 
pressure may be relieved and the 
tissues become dense. Indeed, it 
often appears as if in certain instances 
the progress of the disease was checked 
by such radiation, but owing to the 
great variability in the natural course 
of the primary disease this is doubtful. 
In certain instances large primary 
or secondary malignant growths dis¬ 
appear under the action of radiations 
and at the same time the general 
health of the patient rapidly fails and 
death may ensue. A case of enormous hemolymphangioma of the cervical 
and subclavicular region in an infant three months of age is reported by 
Dominici, Cheron, and Barbarin to have completely retrogressed in seven 
weeks after the introduction for twenty-four hours of a silver tube % 
millimeter in thickness containing 50 milligrams of pure sulphate of 
radium. 

In certain instances benign tumors of the thyroid or large goiters have 
retrogressed to a varying degree by the action of radiations, but carcinoma 
of the thyroid is only in rare instances favorably influenced. Temporary 
relief of distressing symptoms may occur. In cases of exophthalmic goiter, 
especially when the thymus is involved, great improvement may result 
after radiation. In certain instances the region of the thymus alone has 



Fig. 18.— Lymphosarcoma of Neck. 
Photograph taken July, 1919. Note 
scar of previous operation. (From 
Simpson, C. V. Mosbv Co.) 





GENERAL RULES FOR APPLICATION OF RADIUM 575 


been radiated. Unless the dosage is well understood, however, the danger 
of treating such cases must be borne in mind and this is particularly im¬ 
portant when such good results are obtained by surgical methods. 

Thymus .—Eminently satisfactory results have been reported in the 
treatment of enlarged thymus glands in infants. The same results may 
be obtained with the X-rays, but radium has certain advantages. It is 
portable; the desired effect is produced 
in one treatment; it is simple, thus 
eliminating the element of fright 
which is usually present when infants 
are held in a rigid position for X-ray 
treatment. This fixation may be the 
cause of thymic crisis and death. 

Finally, radium application is a safe 
procedure, as the skin tube distance 
never varies even in the case of the 
most refractory child. 

Pathological Conditions of Chest. 

—Individual cases have been cited 
and apparently corroborated by radio¬ 
graphs in which radiation has caused 
the disappearance of thoracic tumors, 
especially in the case of lympho¬ 
sarcoma. Hodgkin’s disease involving 
the bronchial glands and lungs has not 
in our experience shown any per¬ 
manent improvement on radiation. In 
carcinoma of the esophagus it is dif¬ 
ficult to secure accurate apposition of 
radio-active substances but in the 
majority of cases there is marked 
temporary improvement. P atients 
who are almost in extremis from 
starvation may gain thirty to forty 
pounds. This is probably due to the repeated dilatation of the esophagus 
and to the anesthetic effect of the therapy. Recurrences, however, are 
usual. It is possible that application by instruments allowing direct 
observation may improve results, particularly in early cases. 

Diseases of Breast. —The most important disease of the breast which 
is subjected to radium therapy is the recurrent carcinoma. It is the 
general opinion that all operable malignant and benign tumors of the 
breast should be operated upon. Therefore, recurrent or inoperable 
growths form a large part of those treated by radium therapy. The 
minority comprise a few persons who either absolutely refuse operation 



Fig. 19.— Patient in Fig. 18 after 
Radium Treatment. Photograph 
taken in December, 1919. Later 
recurrences took place in throat, 
axillae, inguinal regions and abdo¬ 
men which yielded for a time to 
further treatment. The patient had 
about a year of comfort as the 
result of the treatment. (From 
Simpson, C. V. Mosby Co.) 



576 


RADIUM THERAPY 


or whose general condition will not permit an operation and those who 
are treated postoperatively in prophylaxis of recurrence. In the last class 
of patients it is difficult to estimate the value of such treatment until a 
very large number of cases has been carefully followed out and com¬ 
parative series analyzed. In certain instances recurrent superficial skin 
nodules disappear completely. There is little doubt that the smaller 
and more cellular growths respond quickly to radiation, but at the pres¬ 
ent time proper surgery should be the treatment of choice in all oper¬ 
able tumors of the breast. It is probable that radiation by the deep 
method for very long periods of time may delay the progress of the 
disease even when cure cannot be expected. The great variability in 
the natural history of the disease, however, renders this somewhat doubt¬ 
ful. When the disease is widespread with mediastinal, pleural, or pul¬ 
monary involvement, or there is general carcinomatosis, little can be ex¬ 
pected from radiation. 

Abdominal Conditions. —Certain abdominal tumors become smaller 
and may disappear on deep and intense radiation. In this class are large 
retroperitoneal sarcomata, lymphomata and cases of splenomegaly. Cases 
are reported in which sarcomata and hypernephromata have disappeared. 
Details of the cases are reported by very few, so that it is difficult to 
know the degree and duration of the clinical improvement. In cancer 
of the gastro-enteric system there is little evidence that radiation has 
proved of any value. In the majority of such cases, treated personally, 
there has been a marked relief of pain and patients have even felt that 
it was worth while to go considerable distances for treatment in order 
to secure even temporary relief, usually only a few days’ or occasionally 
a few weeks’ duration. It is, of course, quite probable that a certain de¬ 
gree of relief in these cases of malignant disease was due to the encourag¬ 
ing fact that something was being done. 

In a case of adenocarcinoma of the uterus with transplantation of the 
growth in the fat of the abdominal wall, the large and inoperable mass 
entirely disappeared under two series of intensive radiation by radium. 
After the first series the growth became much smaller and the second 
series was given shortly afterward, instead of allowing the usual four to 
six weeks’ interval, at the entreaty of the patient and her husband, although 
it was carefully explained to them that burning of the skin would prob¬ 
ably result. The latter occurred and it was some months before the pain¬ 
ful burns healed. However, the tumor mass had not recurred two years 
later and the patient’s general health was excellent. This case is an ex¬ 
ception and not the rule. 

Certain cases of ascites from abdominal cancer have been reported 
as relieved, but the variability of such cases naturally leaves the actual 
value doubtful. 

A case of syphilis of the liver, with extremely marked ascites for 


GENERAL RULES FOR APPLICATION OF RADIUM 577 

which very frequent aspiration was necessary, was treated personally bv 
radium applications to the abdomen and the ascites recurred less and less 
frequently. 

It is probable that surgery combined with careful application of radia¬ 
tion would greatly improve the present results in abdominal disease. 

Pelvic Diseases Rectum. —In carcinoma of the rectum, particularly 
adenocarcinoma just above the sphincter, Burnam reports that some cases 
are definitely curable and that in others there is marked improvement 
under radium treatment ; deep carcinomatous ulcers of the rectum are not 
improved, although polypi may do well. Certain of the squamous-cell 
carcinomata about the anus are much improved by radiation and others 
are less so. Preliminary colostomy is advisable. 

Bladder .—Chronic ulcers of the bladder may be improved by radia¬ 
tion, and also papillomata, although in the latter figuration is probably 
preferable. The papillary type of carcinoma is more favorable than the 
squamous-cell variety. In applying radium it is better to open the bladder 
and thus make more exact application for the requisite time. 

Prostate .—It is reported that hypertrophy of the prostate is improved 
in certain instances. Numerous cases have been reported. In our ex¬ 
perience carcinoma of the prostate has not been cured. Larger doses and 
better methods will, doubtless, secure more favorable results. Bugbee 
claims better results from exposure of the prostate suprapubically, de¬ 
struction of the cancer by radium needles introduced through the prostate 
from above, close to and parallel with the urethra, and from needles 
introduced into the prostate through the perineum and late surface radium 
applications accurately made, while drainage is maintained. Application 
to the prostate through the rectum is also advisable. The term “cure” 
should not be used in these cases. 

Testicle .—Embryomata of the testicle, particularly the cellular, so- 
called round-cell sarcoma, may yield to radiation even when the regional 
glands are involved. We now have under observation, in apparently per¬ 
fect health, a young adult in whom there is no sign of recurrence even 
though the inguinal glands were involved when the testicle was removed 
and radiation started two years ago. 

A great deal has been written, particularly within the last few years, 
concerning the value of radium treatment in gynecology. Indeed, the 
subject has been taken up by some of the foremost gynecologists in this 
country and more especially in Europe. About ten years ago, some of 
the European gynecologists made astounding statements regarding the 
beneficial effects of radium in cancer of the uterus; but some of these 
same men l^ter made the most disparaging remarks concerning its use. 
Radium therapy undoubtedly has a large field of usefulness in gynecology. 
The valuable results obtained depend in a large measure upon the in¬ 
tensity of the radiation and the accuracy of the application to the lesion 


578 


RADIUM THERAPY 


to be treated. The resistance of the pathological tissue, the length of ex¬ 
posures and the intervals between them is determined by the clinical judg¬ 
ment of the operator. 

Vulva. —Most, of the patients with carcinoma of the vulva have post^ 
operative recurrences and the majority have metastases. In such cases 
radium therapy has proved of little value, except in cleansing the local 
condition and in relieving hemorrhage. Pruritus and leukoplakia may 
be greatly relieved. 

Vagina .—The fungating type of cancer of the vagina may yield quite 
readily to radiation. In the indurated type results are not good and 
sufficient radiation is apt to cause a formation of fistulse. They are also 
apt to occur in the natural course of the disease whether primary or sec¬ 
ondary. One case was treated personally with radium in which an in¬ 
vasive indurated recurrent carcinoma disappeared and the large vesico¬ 
vaginal fistula resulting was successfully closed by a gynecologist and 
remained healed. 

Leukorrhea may be relieved by radiation, although the possibility of 
at least temporary amenorrhea should be remembered. Polypi of the 
vagina are usually cured by radium therapy. 

Uterus .—In carcinoma of the body such excellent results are obtained 
by proper surgical measures that only for exceptional reasons should 
radium therapy be employed, except in inoperable cases. Of cases of 
carcinoma of the cervix, however, only a very small percentage are dis¬ 
tinctly operable when first seen by a competent physician; it is in this 
group of cases, therefore, that radium therapy finds its greatest usefulness. 

Although much has been written concerning radium therapy in cancer 
of the uterus, not a sufficient number of cases have been studied and 
carefully followed up to recommend any treatment except an operation, 
in cases which are operable, unless the general condition of the patient 
contra-indicates or the family are unwilling to consent to an operation. 
In addition to these inoperable cases radium therapy is used in post¬ 
operative recurrences and after operation in prophylaxis of recurrence. 
In the inoperable and recurrent cases of carcinoma of the cervix the results 
are in a large measure palliative. One unfamiliar with the course of the 
disease as modified by radium treatment would be inclined to think, after 
a few series of treatments, that the condition was cured. The term 
“healed,” applied by some observers, we believe is misleading for the 
reason that under the first few series of radium treatments fungating 
carcinomata of the cervix may disappear, and the ulceration in the ulcerat¬ 
ing indurated type may become less and less and finally apparently heal, 
and the induration about it may be markedly lessened. Suclj a condition 
might be called healed and lead to the natural supposition that the process 
was cured. This, however, is not usually the case. Sooner or later, the 
disease extends, even if it does not recur locally, and the patient sue- 


GENERAL RULES EOR APPLICATION OF RADIUM 579 


cumbs to it. Certain cases, however, distinctly inoperable at the out¬ 
set even with fixation of the uterus and metastases in the vaginal wall 
may, after the primary improvement and local healing, be successfully 
operated upon. Thus, distinctly inoperable cases may exceptionally be 
converted into operable ones. Sometimes growths which respond promptly 
to the first series of radiation later become resistant to all radiation treat¬ 
ment. In certain instances it is desirable to combine local vaginal treat¬ 
ment with applications of radium to the abdominal wall and back, in 
order to increase the cross-fire effect. At least temporary relief from 
hemorrhage, discharge, and pain, and healing of ulceration are common 
in carcinomata of the uterus treated by radiations. Some cases may 
remain well for months or even years. 

After radiation, a small number of cases of carcinoma of the uterus 
develop so-called toxic symptoms which include headache, vomiting, pros¬ 
tration, and rise in temperature. There may also be such local symptoms 
as pain in the back and legs, tenesmus, or frequency of micturition. These 
symptoms disappear in a few days. 

Schauta, in his series of cases in 1913, used intense radiation and 
many of the patients developed extensive local necrosis. The tendency 
of the majority of those using radium at the present time is to use a 
dose of about 100 milligrams of radium element, 2 millimeters of lead or 
1 to 1% millimeters of brass, or its equivalent in silver or platinum for 
filtration and a duration of exposure of twelve hours every few days 
for five to eight treatments. At intervals of six weeks the series is re¬ 
peated. Such cases rarely develop fistuhe or extensive necrosis and there 
is at least temporary local and general improvement. Kelly and Burnam 
have reported that of 199 inoperable cases treated, 53 were clinically 
cured, 108 markedly improved and 37 not improved. Schmitz used 50 
milligrams of radium in cases of carcinoma of the uterus for ten to 
twelve and occasionally twenty-four hours and repeated this after from 
seventy-two to ninety-six hours. After having given a dosage of from 
3,000 to 4,000 milligram hours he gave the treatment weekly, until he 
had given a total dosage of from 8,000 to 10,000 milligram hours. Bumm 
found that all cancer cells were destroyed within a distance of 4 centi¬ 
meters but that they were viable beyond this. Cheron and Rubens-Duval 
made a postmortem examination of a patient dying of an intercurrent 
disease fifteen months after the clinical cure of carcinoma of the uterus 
by radium. In a complete postmortem and careful serial histological ex¬ 
amination they were unable to find cancer cells. 

The scirrhous, inverting type of carcinoma of the uterus seems, usually, 
less improved than the more fungous everting type which tends to in¬ 
volve the vaginal walls. During and between treatment it is important 
that the local condition be kept as clean as possible by a mild cleansing 
solution of boric acid, bicarbonate of soda or potassium permanganate. 


580 


RADIUM THERAPY 


A few cases of chorio-epithelioma have been reported treated by radia¬ 
tion. These cases, in most instances, metastasize to the lungs early. 
Owing to the few cases of sarcoma of the uterus treated no conclusions can 
be drawn. 

Of the benign tumors of the uterus, fibromata and fibromyomata have 
been extensively treated in this country and abroad. Although there is 
much skepticism regarding the results, a large number of cases have now 
been reported in which the size of the growths has diminished or they 
have entirely disappeared. It is admitted that certain small percentages 
seem to be uninfluenced. In the majority of cases, however, not only 
does the tumor diminish in size but the symptoms of menorrhagia or 
metrorrhagia cease. Both intravaginal and surface applications are 
made. Amenorrhea is caused in the majority of cases. Some of the 
foreign clinics report 80 per cent of cures in cases of myomata treated 
by radium. Kelly has used 30 to 724 milligrams of radium inserted 
into the uterus and has, in some cases, given an additional massive 
treatment through the abdominal walls. The treatment requires confine¬ 
ment of the patient to the bed for not over one or two days. 

Menorrhagia and Metrorrhagia .—These conditions, unassociated with 
the presence of tumor, due to various myopathies or neuropathies or to 
disturbed ovarian function are, in the large majority of cases, very greatly 
benefited or cured. Burnam uses 300 milligrams of radium applied 
within the uterus for three hours. This usually causes complete amenor¬ 
rhea. In young women the duration of application is shortened, 500 milli¬ 
gram hours or less, and in such instances menstruation may return. 

L. J. Stacy reports the results of radium treatment in 600 cases of 
menorrhagia and concludes that, while surgery is still the method of 
choice for young women who have definite fibroids causing menorrhagia 
and those with a suspected carcinoma of the fundus, Roentgen rays and 
radium are successful therapeutic agents in carefully selected cases and 
in women over thirty-five. In the treatment of menorrhagia in patients 
more than thirty-five years old, who have a fibrous uterus or a small 
myoma, and in younger patients in whom myomectomy or hysterotomy 
is not indicated or in whom curettage has not controlled the bleeding, 
radium is a very satisfactory therapeutic agent. 

Radium is contra-indicated in pelvic inflammatory disease or where 
there is a history of pelvic pain, since a quiescent infection may be 
lighted up. 

A small dose is given women under thirty-five in order to control 
bleeding but not to cause cessation of menses. It is better to repeat the 
treatment a second time than to cause the menstrual flow to cease entirely 
by too large an initial dose. The average dose used was 293 milligram 
hours for patients under thirty-five and about 700 milligram hours for 
older women. 


GENERAL RULES FOR APPLICATION OF RADIUM 581 

Artificial Menopause. —Radium may be used successfully in cases 
where it may seem desirable to produce an artificial menopause. A routine 
curettage with histological examination of the curettings to exclude new 
growth should precede the application of radium in most cases of uterine 
bleeding even in young women. 


Summary 

Radium has been proved to be a physical agent of unique character. 
It has been shown to have a destructive action upon certain kinds of tumor 
cells. However, the cherished hopes and the fantastic claims that it would 
cure malignant disease and ultimately replace surgery have not been 
realized. In speaking of cures by radium we must be very guarded and 
must consider the type of growth with which we are dealing. Definite and 
permanent cures of superficial cancer of the skin of the basal-celled type 
are obtained in the majority of cases properly treated by radium. Rapidly 
growing cellular types of malignant disease often show astounding tem¬ 
porary regression for varying periods. Malignant tumors which are less 
cellular and those which metastasize early fail, as a rule, to respond so 
well, even temporarily. There are, however, exceptions to this rule. 
Marked clinical improvement, with disappearance of all visible or palpable 
signs of the disease, does not necessarily mean a permanent cure. Care¬ 
ful histological study of these apparently normal tissues will show, in 
the vast majority of cases, that not all the tumor cells have been destroyed, 
but that scattered groups lie enmeshed in fibrous tissue and surrounded, 
perhaps, by lymphocytes—a barrier by no means impervious to subsequent 
growth and metastasis. With complete clinical cure of the primary tumor, 
there may still exist extensive regional or remote involvement. A cure 
can be obtained only when the last single abnormal cell has been destroyed.. 
Up to the present time this has been impossible in the great majority 
of cases. 

The palliative effect of radium in relieving hemorrhage, pain, dis¬ 
charge, foul odor, and in prolonging life temporarily in many instances 
is undisputed. 

There is an occasional case of proved malignant disease, where the 
patient remains cured for ten to fifteen years, and perhaps permanently. 
The undue prominence given to these cases, which ara exceptions rather 
than the rule, has given rise to the extraordinary and fanciful claims 
which have been made by some for the curative power of radium. 

Radium as a medicinal agent taken internally has perhaps some value, 
but as yet there is not sufficient carefully collected data to substantiate 
the claims made for it. 

It is hoped that in the future the accuracy of the diagnosis of all cases 
treated by radium may be carefully corroborated by histologic examina- 


582 


RADIUM THERAPY 


tion of tissue removed for this purpose, and that such cases will be fol¬ 
lowed for end results, so that we may have an ever-increasing volume 
of accurate statistics upon which to base our judgment as to the ultimate 
value of radium as a therapeutic agent. 

Improvement in the results obtained may possibly come in the future 
by the more accurate methods of application of radium to the pathologic 
cells in question, so that fewer escape its destructive action than is at 
present the case. Careful study of the unusual cases which are apparent 
cures for long periods may shed light on the optimum method of applica¬ 
tion and dosage. 


CHAPTER XIV 


X-RAY THERAPY 
John Remer 

Introductory. —The discovery of the X-ray marked the beginning of a 
new era in medicine, from a therapeutic as well as a diagnostic standpoint. 

The physical properties of these rays, by which they can penetrate 
matter opaque to light, and their effect on the photographic plate, af¬ 
forded a means of visualizing conditions within the body, which previous 
to this time could be diagnosed only by their symptoms and clinical signs. 
Their biological action provided a therapeutic agent to combat successfully 
many diseases and conditions which had previously responded unsatis¬ 
factorily, if at all, to medication and other forms of treatment. 

Although numerous other workers had been experimenting along the 
same line, it was Roentgen who, in November, 1895, gave the results of 
his discovery to the world. It was hut a few months after Roentgen’s 
discovery that other experimenters called attention to the biological action, 
namely, that by exposure to the ray, erythema or dermatitis was produced. 
This led to the hypothesis that in the discovery of the X-ray an agent of 
therapeutic value had been found. Its first use was directed to the treat¬ 
ment of the more resistant, and of the incurable, skin conditions, such as 
lupus, epithelioma, and hypertrichosis. 

As is usually the case when a new therapeutic agent is given to the 
profession, the X-ray was considered a panacea. During the next few 
years there was scarcely a condition that was not subjected to this form 
of therapy. The natural result of this widespread, indiscriminate, and 
frequently unintelligent use of so dangerous an agent was that the lit¬ 
erature was soon filled with reports of burns, varying in severity from 
mild vesiculation to a necrosis of even the deeper tissues. Then followed 
a period in which the use of the ray in therapeutics was looked upon 
with great disfavor by the profession at large, only a few of the more 
earnest and persevering workers continuing its use. As a result of the 
painstaking research and experimental work of these few, certain basic 
principles governing X-ray therapy were established. The most impor¬ 
tant of these are: 


583 


584 


X-RAY THERAPY 


1. That the beam of ray as generated by the X-ray tube is not homoge¬ 
neous, but is composed of radiant energy of varying wave-lengths. 

2. That these varying wave-lengths have a different biological action, 
the longer ones having little penetrating power and being absorbed by the 
skin; while those of shorter length penetrate to the deeper tissues. 

3. That on the depth of the lesion depends the type of ray which is 
most effective. 

4. That certain substances, such as aluminum, glass, copper or zinc, 
when interposed in the path of the ray, filter out or eliminate the soft 
rays, that is, those of long wave-length. This makes possible the utilization 
of the type of ray best suited to the case under treatment. 

5. That the skin will tolerate only a limited amount of radiation. 

With the establishment of these principles, there came a reaction, 
and the value of X-ray as a therapeutic agent was established. 


PHYSICS 

X-ray is a form of radiant energy which is produced when a stream of 
electrons, set in motion in a vacuum at a high rate of speed, are suddenly 
stopped. It is similar to light, and travels with the same velocity. 

X-rays move in all directions from the point of source, until absorbed 
by matter. The capacity of matter for absorbing these rays is in direct 
proportion to its atomic weight. The beam of X-rays is heterogeneous, 
being composed of rays of various wave-lengths. The alpha rays are the 
longest, and are spoken of as “soft rays”; the “hard rays,” or those of 
shortest length, approach very nearly the gamma rays of radium. X-rays 
are invisible, and can be detected only by their action: first, on the photo¬ 
graphic plate; second, on certain crystals; third, on tissue (biological 
action) ; fourth, on the ionization chamber; and fifth, by their place in 
the spectrum. 

In order to produce X-rays it is necessary to have: 

1. A vacuum. 

2. A source or supply of free electrons. 

3. A heavy metal “target,” placed in the path of the stream of 
electrons. 

4. A means of setting the electrons in motion at a high rate of speed. 

The first three are found in the X-ray tube, while the fourth is sup¬ 
plied by some form of electrical apparatus, that known as the “X-ray 
transformer” being the most efficient. 

X-ray Tube. —The X-ray tube is a glass bulb, from which all, or 
nearly all, of the air has been pumped. At either end is an electrical 


PHYSICS 


585 


terminal, and within the tube are placed the anode, or “target,” which is 
usually made of tungsten, and the cathode, which is usually a cup-shaped 
metal disc, so arranged as to focus the stream of electrons on the center 
of the target. There arc in use to-day two types of tubes: first, those 
depending for the electrons on a small amount of gas left within them, 
called “gas tubes”; seco’nd, those which supply electrons from a heated 
wire or filament placed at the cathode, and known as the hot cathode, or 
more familiarly, “Coolidge tubes,” in honor of their inventor, Dr. W. D. 
Coolidge. 

Gas Tubes.—Gas tubes contain a small amount of air (or other gas), 
from which in its rarefied state electrons are readily liberated. The 
current entering at the cathode directs these electrons against the target 
(at a speed equal to'one-third to one-half the velocity of light) where 
they are abruptly stopped, and at which point the X-rays are generated. 
Continued use diminishes the supply of electrons and causes the tube to 
become hard; that is, it requires greater voltage to operate. Therefore 
a device must be supplied that will permit more gas to be admitted as 
required. To accomplish this, a valve containing certain chemicals 
(usually mica or asbestos) is placed in the side of the tube. When a small 
discharge current is passed through this valve, gas will be liberated into 
the tube. This procedure is called “softening.” The tendency of the gas 
tube to harden makes impracticable its use in therapeutics, where a con¬ 
stant and uniform tube resistance must be maintained, since a change in 
this factor alters the character and amount of the radiation produced, and, 
also, any variation makes it impossible to estimate accurately the amount 
of radiation generated. 

Coolidge Tube.—The general construction of this tube is similar to 
that of the gas tube, hut the air is exhausted to such a point that the great¬ 
est possible vacuum is obtained. In the cathode is placed a coil of tungsten 
wire connected to a low voltage electric current (supplied by a storage 
battery or a step-down transformer). When the circuit is closed the coil 
(or filament) becomes heated and liberates electrons. The hotter the 
filament, the “softer” the tube. By means of a current control the tem¬ 
perature of the filament can be regulated at will, so that the tube may 
he maintained at any given degree of hardness for an indefinite length of 
time. It was the advent of this typo of tube that overcame one of the 
greatest difficulties confronting the radiotherapeutist, and since its inven¬ 
tion the progress of radiotherapy has been marked. 

Transformer.—In the early days of the X-ray, the electrical current 
was supplied by static machines. These were soon replaced by various 
types of induction coils, which, although more satisfactory, have in more 
recent times been supplanted almost entirely by the “interrupterless trans¬ 
former.” This machine consists of a primary winding around a soft 
iron core, and an extensive secondary winding, in which the high tension 


586 


X-RAY THERAPY 


or secondary current is induced. The current supplied to the primary is 
usually 110 or 220 volts, and must be alternating current. The current 
obtained from the secondary is from 10,000 to 200,000 volts, and is also 
alternating. In order to operate the X-ray tube direct current is required, 
and a rectifier is placed in the secondary circuit which makes it possible 
to deliver the proper type of current to the tube. 1 

There are certain electrical and physical factors which govern the 
quality and quantity of X-ray, and by which the amount of radiation 
applied may be estimated. In considering the amount of exposure, these 
factors are most important, and it must be borne in mind that a change 
in any one of them alters the character or amount, or both, of the radia¬ 
tion applied. The important factors are: spark gap (voltage), milli- 
amperage, distance, time, and filter. 

Spark Gap (the Unit of Voltage ).—The unit of measurement of 
difference in potential between the positive and negative side of an elec¬ 
trical apparatus is the volt, and is usually measured by a voltmeter. Due 
to various mechanical and electrical difficulties, it has been, in the past; 
advisable to use an approximate method of measuring the high-tension 
voltage instead of a meter. Electrical currents always follow the path 
of least resistance. The X-ray tube offers resistance which varies in 
direct proportion to its hardness. If a wire or metal rod is so placed that 
it can be extended from one side of the secondary line toward the other, 
a point will be reached at which the current will encounter less resistance 
by jumping the gap between this rod and the other side of the circuit 
than in passing through the tube. This space is called the spark gap 
(S. G-.) and has been the commonly used method of expressing voltage 
in computing the amount of X-ray administered. 

A one-inch gap represents, approximately, 20,000 volts, and each ad¬ 
ditional inch represents 10,000 volts, so that a nine-inch spark gap is 
considered equivalent to 100,000 volts. In the latest type of machine 
(the 200,000-volt) there is a tendency to speak in terms of volts rather 
than spark gap. Also, in these machines the measure of the spark gap is 
between spheres instead of points. 

Any change in distance that the current will jump represents a change 
in voltage; hence a change in the quality of radiation. The longer the gap, 
the more penetrating the ray. In radiotherapy a six to fourteen-inch spark 
gap is employed. 

Ampere. —The ampere is the unit of electrical current and represents 
the amount of electricity passing a given point in a certain length of 
time. In roentgenology the amount of current used in the secondary line 
is so small that the measurement is the milliampere, and represents one- 

1 Certain types of tubes can be operated on alternating current, and the modern 
portable or bedside X-ray outfit is thus made possible. In treatment, however, this 
type of tube and machine is impracticable. 



PHYSICS 


587 


thousandth of an ampere. Any change in the milliamperage changes 
the quantity of radiation. The higher the milliamperage, the less time re¬ 
quired to produce a given amount of ray with a given spark gap. In 
radiotherapy two to seven milliamperes are usually employed, a greater 
amount causing the tube to heat too rapidly for practical therapeutic pur¬ 
poses. Furthermore, longer irradiation is frequently advantageous on ac¬ 
count of the greater amount of secondary radiation produced. 

Distance.— Distance represents the number of inches or centimeters 
from the target of the tube to the nearest surface of the body. This 
factor is varied according to the preference of the operator. 

Time. —This factor is the actual time that the X-rays are being 
directed to the surface under treatment. 

Filter.— In order to eliminate the soft rays, various substances are 
interposed between the skin and the target of the tube. The filter is placed 
in a slide arranged in the tube-stand for that purpose. The substances 
generally employed are glass, aluminum, brass, copper and zinc. Sole 
leather is used by some, as are paper, chamois skin and silk, but these are 
of questionable value. The greater amount of filtration used, the less 
total radiation reaches the patient, hut, as the soft rays are the most 
easily eliminated, it is possible, by proper filtration, to utilize only the 
most penetrating rays, thus delivering a more homogeneous ray. 

Another factor, which is of importance in considering the amount of 
radiation delivered to the lesion, is the size and number of areas treated. 
Depending somewhat on the choice of the operator, but more on the loca¬ 
tion and character of the lesion, this factor varies greatly. In super¬ 
ficial therapy it is necessary to expose an area only slightly larger than the 
lesion itself. In deep therapy, however, it is frequently necessary to ex¬ 
pose the anterior, posterior and lateral surfaces of the body, in order to 
deliver to the lesion a sufficient quantity of ray without injury to the 
skin. Again, by exposing small areas and carefully shielding the sur¬ 
rounding skin, it is possible, without harm to the patient, to give much 
larger quantities of ray to a given portion of the body than if only one 
area were used. Furthermore, the larger the area exposed, the greater the 
amount of secondary radiation produced. 

Ho absolute or fixed rule can be given governing the conduct or treat¬ 
ment of any particular condition, and in outlining the treatment of various 
diseases, the author is merely indicating the method found beneficial in 
the treatment of the majority of cases. It must be remembered, however, 
that every case is an individual one, and that the success of the radio¬ 
therapeutist depends, above all, on his ability to recognize the special re¬ 
quirements of each patient, and his ingenuity in meeting them. 

To say that accurate diagnosis is of the greatest importance, and that 
X-ray treatment should never he undertaken until it has been established, 
may seem an affront to the profession. However, as results depend largely 


588 


X-RAY THERAPY 


on proper technic, and since this technic varies so widely, there is con¬ 
stant danger either of affording no relief or of actually doing harm, 
unless a correct diagnosis is established. This applies not only to super¬ 
ficial therapy, in which various lesions may so closely resemble each other 
as to be indistinguishable to the untrained observer, but to the entire field 
of deep therapy as well. 

In the development of the 200,000-volt technic, every effort is being 
made to standardize all factors, and extensive experimental work has been, 
and is being, conducted by radiotherapeutists in collaboration with physi¬ 
cists and biologists. Absorption of X-ray by tissue has been carefully 
studied, and curves plotted to show the exact amount absorbed by each 
successive centimeter. Investigations are being conducted to estimate the 
amount of secondary radiation produced. In this work the ionization 
chamber is employed to measure the amount of radiation, and in every 
way efforts are being made to advance the technic along thoroughly sci¬ 
entific and absolute lines. However, the fact must not be overlooked that 
medicine in all its branches is an art, and not a science; that biological 
reaction cannot be accurately measured, nor can the effect of an agent on 
living, cellular life be considered the same as its effect on inorganic or 
non-living material. So that, while this work is in the right direction 
and of inestimable value, the individuality of each case must govern its 
treatment. 

In the use of the newer method there is considerable variation in 
technic. Filters employed vary from % to 1 millimeter of copper plus 
1 millimeter of aluminum. The distance ranges from 40 to 100 centi¬ 
meters, and the area of exposure is from 10 to 25 centimeters square. 

By accurately locating the tumor, carefully measuring the body, and 
from the charts of absorption curves estimating the number of portals 
and amount of radiation necessary to each portal, the growth will receive 
the required percentage of an erythema dose, and at no point will the skin 
receive a greater amount than is compatible with safety. 


GENERAL CONSIDERATIONS OF X-RAY THERAPY 

Before beginning a discussion of the merits and limitations and the 
various methods of administering X-ray for therapeutic purposes, it is 
desirable that there should be a clear conception of its action. In speak¬ 
ing of the various means of detecting the ray, the biological action and 
its effect on living cells was described. This effect is inhibitory and varies 
in degree in direct proportion to the amount of radiation applied. If 
sufficient is administered, complete destruction or necrosis of the cell 
follows. 


GENERAL CONSIDERATIONS OF X-RAY THERAPY 589 

Some investigators believe that minute exposures have a stimulating 
action, hut the author does not agree with this contention, believing that 
the action of the ray is always inhibitory. It is true, especially in neo¬ 
plasms, that insufficient radiation will frequently be followed bv an 
increased activity of the tumor, but this is probably due to an inhibition 
of the surrounding normal tissue and interference with the normal blood 
and lymph supply to the part, instead of to a stimulation of the growth. 
The same result will be produced by too prolonged radiation. 

The response of tissue to radiation varies according to the type of 
cells of which it is composed. Normal cells are more resistant than patho¬ 
logical, and the nearer the cell approaches the embryonic type, the greater 
and more complete the effect. Conversely, the more closely the pathologi¬ 
cal approaches the normal, the greater its resistance. But this resistance 
is always below that of the normal. Ewing states that while normal 
lymphoid tissue is very resistant to the action of the ray, the same type, 
when pathological, is quite easily destroyed by it. It is due to this fact 
that it is possible to use the X-ray therapeutically, for when the ray 
is applied to a pathological area, normal tissue is necessarily exposed to 
its action, and, were all cells equally affected, it would not be possible 
to destroy the diseased tissue without at the same time destroying normal 
structure. Obviously, it is the area of the skin nearest the target that 
receives the greatest amount of radiation; hence the limit of ray that can 
be applied must be no greater than the skin will bear without serious 
injury. 

The second, and equally important, factor in tissue response is its 
ability to recover from inhibition. This recovery is in inverse proportion 
to the degree to which it is affected, the tissue most, difficult to affect 
recovering most rapidly and most completely. Since the pathological 
cells recover less rapidly and less completely than the normal, it is possible 
to administer a second exposure as soon as the normal structures have 
recovered and while the pathological are still inhibited. This second 
radiation still further inhibits the lesion without injury to the normal 
tissue, and by repeated exposures it may be possible to destroy the lesion 
completely. 

Thus it can be readily understood that cases selected for X-ray treat¬ 
ment must be those in which there is pathological tissue present, and this 
pathological tissue must be simple inflammatory, chronic inflammatory, 
granuloma or neoplastic; that it must be possible to destroy the tissue 
without causing serious injury to normal structures. In fibrous lesions, 
where only connective tissue is present, no benefit will be derived. 

Although all tissues will return to their normal activity within a 
definite time, after being subjected to the action of the X-ray, their re¬ 
sistance remains lowered for a much longer period. Consequently, if 
treatments are continued for too long a time without suitable intervals of 


590 


X-RAY THERAPY 


rest, atrophy of the skin and subcutaneous tissue will result, although at 
no time has there been sufficient radiation administered to cause even a 
mild erythema. Some tissues, most noticeably carcinoma, seem to acquire 
a tolerance for X-ray. In cases of cancer it has frequently been noted 
that, although at first satisfactory progress was made, later the neoplasm 
increased in size, and the condition of the patient became steadily worse, 
even though the same or even a greater amount of radiation was admin¬ 
istered. To this fact is due the present-day effort of therapeutists, espe¬ 
cially those using the more recent high-power machines, to administer 
the full, so-called, carcinoma or sarcoma lethal dose at a single treatment. 


EFFECT OF X-RAY THERAPY ON TISSUES 

Skin. —As mentioned above, the effect of the X-rays on the skin is 
the guide to the amount of radiation that can safely he administered. If 
the amount of radiation is increased beyond safe limits, there is pro¬ 
duced: (1) erythema; (2) vesiculation and depilation; and (3) ulcera¬ 
tion and necrosis. Complete and permanent alopecia may result, and the 
functions of the glands may he permanently inhibited. This subject will 
be treated at greater length in a subsequent paragraph. 

Circulatory System — Blood .—Within twenty-four hours after radia¬ 
tion there is an increase in the white blood count, due entirely to new 
polymorphonuclear elements. The lymphocytes are decreased, resulting 
in a leukocytosis, together with a lymphopenia. The increase in the 
polymorphonuclear cells is probably caused by destruction of the lympho¬ 
cytes, which calls upon the body for increased phagocytic action. . This 
condition persists only a short time, perhaps only a few hours, and is 
succeeded by a true leukopenia. This reaction, to a varying degree, 
always follows the administration of X-ray, but unless the blood-forming 
organs are radiated, the effect will be very transitory. Hence, in order 
to obtain beneficial results in the leukemias, the long hones, the spleen, 
and lymphatic glands must he exposed. 

The effect on the red cells is slight, and it is only after massive 
administration that the presence of degenerated, or nucleated, forms is 
noted. Some authors consider this effect of great importance, at¬ 
tributing to it a peculiar cachexia which has been observed after prolonged 
radiation. 

The theory has been advanced, and some experimental work has been 
done to prove, that X-ray causes an increase in the antibodies of the blood. 
Clinically it is well demonstrated that results are obtained in parts of the 
body distant from those radiated. In Hodgkin’s disease, frequently only 
the trunk is radiated, regardless of the position of the glands involved, 
and yet a diminution or disappearance of all affected glands is obtained. 


EFFECT OF X-KAY THEEAPY OX TISSUES 


591 


Again, in leukemia, blood taken from a patient who had received radia¬ 
tion was injected into a second patient suffering from the same disease, 
but who had not been so treated. The white blood count of the latter 
was reduced. When this same experiment was tried, using the blood 
of a non-radiated patient, no such result was obtained. It is believed 
by some workers that this antibody reaction is an important factor in 
carcinomatous conditions, and that the beneficial results are due to it, 
as well as to tne destructive action of the ray on the neoplasm. The 
coagulation time of the blood is materially shortened. 

After a very massive exposure, especially about the head and neck, 
an edema in the area exposed is frequently observed. This is variously 
accounted for, some workers contending that it is due to vasodilatation 
with consequent venous stasis; others holding that a proliferation of the 
lymphatic endothelium is produced, which causes a lymph stasis. The 
latter view seems to be the correct one, and is of importance in the pre¬ 
operative radiation of malignancy. 

Eyes. —The widespread belief that the eye is especially sensitive to 
the X-ray seems to be without clinical foundation. Although it is true 
that conjunctivitis, superficial keratitis, iritis, retinitis, and even optic 
atrophy have been experimentally produced in small animals, it was only 
after radiation had been carried far beyond the amount tolerated by the 
skin. In actual practice, it has been found that the vision is in no way 
impaired when the eyes are unprotected during treatment of lesions about 
the face, lupus, epithelioma, etc. As a precautionary measure, most 
workers, when exposing lesions of the face, cover the eyes with a lead 
shield; and while this is probably unnecessary, the medicolegal aspect 
must ever be borne in mind, and operators will do well to employ all 
possible precautions. 

Kidneys. —Xormal kidney tissue is not affected by X-ray administered 
in therapeutic amounts. Nevertheless, massive radiation of the body is 
sometimes followed by clinical and urinary evidence of acute nephritis. 
This is probably the result, not of the action on the kidneys, but of the 
added strain placed upon them in consequence of the sudden liberation 
into the blood-stream of toxic material from the disintegrated tissues 
which received radiation. In kidneys already pathological, such a neph¬ 
ritis is more apt to occur and to prove more serious. 

Nervous System. —Nerve tissue is not affected by rational exposures. 
Tumors of the brain have been successfully radiated and no evidence of 
impairment of brain function followed. 

Lungs.—It has been observed that prolonged radiation over the thorax 
sometimes causes fibrotic changes in the lungs. Several cases have been 
reported in which pleural effusion followed the application of massive 
exposures with the 200,000-volt technic. Otherwise there is apparently 
no effect. Both the effusion and the fibrosis disappear. 


592 


X-EAY THEEAPY 


Thyroid and Thymus. —The effect on the thyroid has been recognized, 
and the X-ray used for treatment of toxic hyperthyroidism for many 
years. Moderate amounts of the ray cause a decrease in. the function, 
and if sufficient ray is administered myxedema will result. This effect 
is considered by many physicians to be a contra-indication to the use of 
radiotherapy for lesions around the throat and neck. Such contention 
is not justified by the experience of radiotherapeutists, who find that to 
influence hyperthyroidism the ray must be directed to the gland itself, 
and that prolonged series of radiations for cervical adenitis, and the 
procedures followed in treating hypertrophied tonsils, do not cause the 
slightest evidence of diminution of thyroid secretion. 

Larynx. —Over-radiation of the larynx may cause temporary or perma¬ 
nent aphonia. 

Spleen. —This organ is especially sensitive. By animal experimenta¬ 
tion it has been found to shrink rapidly after being exposed to the ray. 
At necropsy it was found to be shriveled and discolored, the cellular 
elements destroyed, and the lymphocytic nuclei disintegrated. 

Gastro-intestinal Tract —Salivary Glands .—Exposures to even a sub¬ 
erythema intensity of filtered radiation may be followed by dryness of 
the mouth and throat, which persists a day or two, due to an inhibition 
of the glandular activity. If sufficient exposures are given, permanent 
loss of the activity of these glands will result. 

Stomach .—Cases of hyperacidity treated by X-ray have had the 
amount of acid reduced, and their symptoms relieved. While no special 
investigative work on this subject has been recorded, it seems reasonable 
to suppose that all glandular activity may be inhibited by the X-ray; 
hence, not only the hydrochloric acid glands, but all others as well, are 
probably inhibited. 

Intestine .—Martin and Eogers, in their investigations, found that 
massive exposures to X-ray, particularly with the 200,000-volt machine, 
directed over the intestines, caused an endothelial necrosis. Having de¬ 
termined the quantity of radiation necessary to produce an erythema on 
a dog’s skin, they exposed a loop of the animal’s intestine (laid on the 
belly wall after laparotomy) to the direct action of the ray. Two groups 
of animals were radiated; the first receiving the erythema exposure, the 
second, twice that amount. 

At the end of three weeks the first group of animals showed no clinical 
evidence of any untoward effect of the ray. An autopsy performed at 
this time showed that the exposed loop of intestine was shortened two- 
thirds of its length, its lumen narrowed, its epithelium desquamated, and 
all villi absent. The loop was hyperemic, the mucosa thickened, and the 
muscularis vacuolated. 

Animals of the second group were clinically well on the fourteenth 
day, but refused food on the sixteenth. They then rapidly lost weight, 


EFFECT OF X-EAY THEEAPY OX TISSUES 


593 


and on the nineteenth day their condition was such that they had to be 
killed. At autopsy the same condition was found as was observed in 
Group 1, but to a more advanced degree. Their conclusions in part are: 

1. The erythema dose for a dog’s skin, when applied directly to the 
intestines, produces hyperemia, marked contraction in all directions, and 
destruction of the epithelial lining. 

2. The intestinal damage to dogs, resulting from direct radiation, 
does not always produce early death. 

3. Bloody diarrhea, ulceration, perforation, and stenosis, occurring 
in patients subjected to deep therapy for abdominal lesions, may be due 
to direct intestinal injury. 

4. Eoentgen cachexia is possibly due to the same cause. 

These experiments are of particular value at the present time, since, 
in the attempt to overcome carcinoma, efforts are being made to deliver 
a “depth dose” of 110 per cent of the erythema exposure. 

Reproductive Organs.— The belief that sterilization may follow the 
least exposure to X-ray is so firmly fixed in the minds of many that it 
seems advisable to speak at some length on the subject, in order that the 
widespread fear of the ray, on this account, may be dissipated. 

It is true that both the testicles and ovaries are sensitive to the ray, 
and that, following sufficient exposure, aspermia or premature menopause 
will occur. The effect is mainly on the germinal epithelium, which can 
be completely destroyed, but only after relatively heavy radiation, cer¬ 
tainly not after a single fractional exposure, such as is received by persons 
visiting an X-ray laboratory at infrequent intervals. 

By animal experimentation, it was found that one-third of an erythema 
exposure, directed to the testicles, caused a disintegration of the sperma¬ 
tozoa and a diminution in their number. 

Complete sterilization results only from massive doses, the so-called 
castration dose with the 200,000-volt technic being placed at about 40 per 
cent of the maximum amount tolerated by the skin. In the experience 
of the author it requires a suberythema exposure, filtered, applied to each 
of seven ports of entry, and repeated at four-week intervals, two to four 
times, to produce a premature menopause. 

Before the biological effect of the ray was understood, and protective 
precautions observed, many radiologists or their technicians were being 
constantly exposed to the ray. It was found that after from one to five 
years, numerous operators developed aspermia. Later investigation of 
these cases showed that this condition disappeared in about two years 
if the work was abandoned or suitable protection used. The technical 
workers of some of the large experimental laboratories are now protected 
by a special lead and leather garment, and, although they are exposed to 


594 


X-RAY THERAPY 


excessive amounts of X-radiation, they are not made sterile. Ample pro¬ 
tection is afforded by the lead rubber apron in common use. There is no 
reason to fear causing sterility unless the testicles or ovaries are to be 
exposed. Where exposures about the pelvis are to be made, suitable 
X-ray protective material should be placed over the ovaries or testicles, 
or, if these organs must be exposed, the patient should be warned of the 
probable result before the treatment is undertaken. 

Steiger reports an interesting case treated for uterine fibroid. Prior 
to 1907 the woman had had four children; there were no further preg¬ 
nancies until 1914, at which time she aborted at the tenth week. In 1917 
she was found to have a fibroid, complicated by hyperthyroidism. The 
patient was treated for both of these conditions on June 7 and 21, July 5 
and 19, and August 2. She menstruated July 19 and 28, three days 
each time. Ho further menstruation after September, 1917. Treat¬ 
ment of the thyroid was continued until May, 1918. She became pregnant 
in September, 1919, and in the latter part of April, 1920, was delivered 
of a normal child. 

Pregnancy. —Although malformations and monstrosities have been 
hatched from chickens’ eggs that have been exposed to radiation, there 
are no cases in the literature which show any untoward effects following 
radiation during human gestation. 

Bacteria. —It has been found by experimentation that, the beta ray is 
the most destructive to microorganisms, which have been killed at a depth 
of 2 millimeters below the surface of gelatin media. The amount of 
radiation required is so excessive that in living tissue no direct bactericidal 
effect can be obtained by therapeutic amounts. It is nevertheless true that 
many skin lesions of recognized bacterial etiology respond favorably to 
radiation. Many theories have been advanced to account for this, such 
as increased phagocytic action of the blood-cells; production of bacteri¬ 
olytic enzymes; and one investigator was able to demonstrate an increased 
opsonic index after radiation. Whatever the explanation of this may be, 
the fact remains that areas radiated do tend to become free from bacteria, 
as is well illustrated in the treatment of diphtheria-carriers, the cultures 
from whose throats become negative after one or two exposures. 


RADIODERMATITIS 

Following an X-ray exposure there is, as has already been stated, an 
inhibition of all tissues. If the amount has been small, a return to normal 
will occur in a short time without any physical manifestations. If, how¬ 
ever, the exposure has been of sufficient intensity, there will follow, in a 
period of from a few days to two weeks, an erythema or radiodermatitis. 
This must not be confused with the erythema which frequently appears 


RADIODERMATITIS 


595 


in from one to twenty-four hours following an exposure and disappears 
in from twenty-four to forty-eight hours, due, according to Pfahler, to 
electrostatic discharge, and can be prevented by grounding the lead-foil 
protective. 

Radiodermatitis is of three degrees: first, second, and third. 

The first degree is characterized by an erythema which appears in 
from seven to fourteen days, and varies in intensity from a faint blush 
to a deep red, reaching its maximum in about two weeks, and disappear¬ 
ing in about four weeks. It is followed by mild pigmentation or tanning, 
which may last several weeks or months, gradually disappearing. 

If the exposure has been on a hairy part, an alopecia will result which 
may be either temporary or permanent. This- reaction is accompanied 
by a slight burning or stinging sensation and itching. 

In second-degree radiodermatitis, the erythema is apt to appear some¬ 
what earlier than in one of the first degree. It is characterized by 
erythema, vesiculation, exudation and excoriation, accompanied by a 
burning, stinging sensation, which may be severe and distressing. Second- 
degree radiodermatitis usually requires several weeks, or even two or 
three months, to heal, depending on its severity and the extent of the area 
involved. 

In third-degree radiodermatitis it is difficult to draw a sharp line of 
demarcation between a severe second and a mild third. It is character¬ 
ized by all the symptoms of the second degree, and in addition there is 
always an ulceration of the true skin. The erythema usually appears 
in three or four days, and, as a rule, the earlier the appearance of the 
erythema the greater the severity of the radiodermatitis. Almost from its 
first appearance the erythema is a dusky or even purplish red, and usually 
there is an ulceration of the skin, subcutaneous tissue, and there may be 
an involvement of even the deep muscular tissue and fascia. It is accom¬ 
panied, to an exaggerated degree, by all the symptoms of second-degree 
radiodermatitis, and, in addition, the pain is exceedingly severe. 

Sequelae.—The first degree results in tanning, which will disappear 
as a rule within a few weeks or months following a single exposure. If 
repeated erythemas are produced, atrophy will result, followed in six 
months to one year by telangiectasia and permanent alopecia if hairy 
portions are involved. It is an axiom to bear in mind: Never produce 
an erythema, especially in an exposed part, unless the condition warrants 
the possibility of subsequent atrophy and telangiectasia, that is, in 
epithelioma, lupus vulgaris, etc., but never in acne, tinea tonsurans, etc. 

The second degree results in atrophy, alopecia, telangiectasia, and later 
keratosis, which may degenerate into epithelioma, which is always of 
the squamous or prickle-cell type. 

In the third degree, while there may be healing after a period of a 
few months, with resulting telangiectasia, atrophy and keratosis, which 


596 


X-RAY THERAPY 


is more likely to degenerate into a prickle-cell epithelioma, the usual 
result is an indolent ulcer. 

Treatment —First Degree .—The first degree usually requires no treat¬ 
ment. If the burning or itching is annoying, a lotion of calamine and 
zinc in witch hazel may be used. One or 2 per cent carbolic acid may 
he added. Unguentum aquae rosae or vaselin may be all that will be 
required. 

Second Degree .—If there is no vesiculation, the calamine and zinc 
may be used, or an ointmerft containing 1 to 3 per cent icthyol may be 
used in combination with zinc oxid. 

R 

Iehthyol—1 to 3 per cent 
Zinc Oxid 
Png. Aq. Eosae 

To this may he added phenol 1 to 2 per cent, or menthol gr. 1 to 3. 
If vesiculation and exudation are present, a wet dressing is to be pre¬ 
ferred, but it must be borne in mind that the exudation (degenerated 
cell products) is extremely irritating, and, wherever it comes into con¬ 
tact with the normal skin, will give rise to an acute eczematous condition. 
To avoid this, the surrounding normal tissue should be covered with a 
layer of vaselin before the wet dressing is applied. The following dress¬ 
ing, suggested by Dr. David Satenstein, will be found of service. 


IJ Parts 

Boracic Acid. 4 

Sodium Chlorid . 10 

Sodium Bicarbonate . 20 

Aq. q. s. ad. 100 

Apply locally. 


Third Degree .—The most marked symptom of third-degree radio¬ 
dermatitis is the severe pain, and it is to this that the principal treatment 
must be directed. While local applications may afford some relief, it is 
frequently necessary to resort to internal medication. In mild cases 
the coal-tar products will be sufficient, but in severe ones it may be neces¬ 
sary to resort to morphin or codein. These drugs must be used with 
extreme caution to avoid the danger of drug addiction. 

The wet dressing of boracic acid may be used, or an ointment contain¬ 
ing 5 to 10 per cent of anesthesin will often afford some relief. After 
separation of the slough, the pain becomes less severe. At this stage an 
ointment of icthyol, 1 to 3 per cent, is indicated. 

If an indolent ulcer results, healing may be produced, or at least 
aided, by use of the Kromayer or Alpine sunlamp. 

In extreme cases, or if healing has not taken place in a year, it is 
advisable to excise the entire affected area and skin graft. 

o 






RADIODERMATITIS 


597 


Idiosyncrasy.—Severe reactions, occasionally occurring when the ex¬ 
posure apparently has not been excessive, are explained by so-called 
“X-ray idiosyncrasy.” 

As technic improved, untoward results became less frequent, and 
to-day the existence of true idiosyncrasy is denied by the best workers. 
Exposures which produce unexpectedly severe reaction can usually be 
traced to some error in judgment or inaccuracy in technic. 

There may be a hypersensitiveness, and certain conditions do influence 
the action of the ray. A blond skin is more sensitive than a brunette. 
The flexor surfaces of the body are more sensitive than the extensors. 
Age is a factor, children being more susceptible than adults, and a young 
adult more than an aged person. Certain drugs enhance the action of 
the ray and positive information as to the length of time since their last 
use must be obtained before irradiation is determined upon. 

One of the most constant sources of danger is inaccuracy of the milli- 
amperemeter, a slight variation in its reading being a frequent source of 
error in exposure. To avoid this, two milliamperemeters should he used 
in series. If this is impossible, the one employed should be tested fre¬ 
quently. All factors must be maintained constant during an exposure, 
since a variation in any one means a change in all. 

The area surrounding the part to be irradiated should he protected, 
and injury through failure to use this precaution is unjustifiable. During 
exposure the patient must be constantly under observation, for any one of 
the many accidents which might occur may result in the death of the 
patient unless the operator is prepared for the emergency. Accurate 
records of every detail of the treatment must he kept, as in radiotherapy 
the medicolegal aspect must be constantly borne in mind. 

The following drugs should never be employed within two weeks pre¬ 
ceding, during, nor two weeks subsequent to, the use of X-ray. In the 
ordinarily used formulae they are keratoplastic, and in strong solutions 
they are keratolytic. X-ray lowers cell vitality in all tissues. When this 
occurs in an area where these drugs have been used, this action becomes 
more powerful, and the keratolytic action of the drug follows. 


Iodin 

Iodoform 

Resorcin 

Oil of Cade 

Coal-tar Preparations 

Loti a Alba 

Silver Nitrate 

Stronger Mercurial Prepara¬ 
tions 
Ice 


Heat 

Musterole 

Baume Analgesique 

Beta Naphthol 

Chrysarobin 

Gasoline 

Benzin 

Turpentine 

Scarlet Red 

Sulphur 


598 


X-RAY THERAPY 


Benzoic Acid Stronger Ammonia 

Balsam of Pern Preparations 

Mustard Chloroform 


The action of the following drugs, in connection with X-ray, has 
not been definitely determined, and they should be used with extreme 
caution. 


Camphor 


Chloral 


The following drugs may be used: 


Phenol up to 2 per cent 
Alcohol 

Magnesium Carbonate 
Vaselin 


Zinc Oxid 
Boracic Acid 
Bismuth 
Lanolin 
Picric Acid 


Menthol 


Icthyol 1 to 3 per cent 

Calamine 

Bay Rum 

Ether 


METHOD OF COMPUTING X-RAY INTENSITY OR DOSAGE 

Unfiltered Radiation 

In radiotherapy it is necessary to establish an accurate method of 
measurement of the quantity of X-ray administered. 

In 1904 Sabouraud and Noire devised the first practical means of 
measurement, making use of Villard’s discovery that the platinocyanid 
of barium is colored by exposure to the X-ray. They found that when 
exposed to an amount of radiation sufficient to depilate the scalp, the color 
of this chemical changed to orange. They then made a radiometer hav¬ 
ing a scale of two colors, the first, which they called tint “A,” correspond¬ 
ing to the unexposed chemical, and a second, called tint “B,” corresponding 
to the orange. By exposing a fresh pastille of barioplatinocyanid to the 
X-ray and comparing it to the standard scale, the operator was able to 
determine the so-called erythema exposure. 

Later, Holzknecht devised his radiometer, which was without doubt 
the best instrument for use with pastilles. Utilizing the same principle 
as Sabouraud and Noire, he established a color scale with finer gradations. 
Such a scale was necessary in order to give fractional treatment. The 
different shadings were called H-l, H-2, etc., H-4 being the amount 
necessary to depilate the scalp, and H-5 the equivalent of tint “B” of 
Sabouraud and Noire. This scale was graduated to H-32, or 8 skin units. 

The fact that the pastilles made by the various manufacturers were 
not uniform; that unless carefully preserved they were liable to change 
color; that the celluloid band or index was not permanent, after a time 


COMPUTING X-RAY INTENSITY OR DOSAGE 599 

in the upper scale changing to a yellowish green; and that it was difficult 
to obtain fresh bands, made their use impractical. 

In 1916 the author, in collaboration with Dr. Witherbee, conducted a 
series of experiments to devise, if possible, a means of measuring X-ray 
dosage by the use of definite factors—spark gap, milliamperage, time, 
and distance—in order to obviate the use of pastille and radiometer. The 
results of the experiments were published in 1917. 

In measurement of photographic intensities it was shown by Shearer 
that by doubling the voltage, four times the amount of radiation, and 
that by doubling the distance, one-quarter of the amount reaches the 
plate. His formula was as follows: 

Voltage X Voltage X Current X Time 


Distance X Distance 

For convenience, suppose the following factors are taken: 


5 

Inches Spark Gap 

(voltage) 

20 

Milli amperes 


4 

Minutes 


20 

Inches Distance 


then 

5 X 5 X 20 X 4 

2000 


20 X 20 

400 


If the voltage be doubled, the intensity will be increased four times, 
as expressed by the following formula: 

10 X 10 X 20 X4 8000 
-=-— 20 

20 X 20 400 

However, when this rule was applied to X-ray dosage from the stand¬ 
point of pastille measurement, it was found that doubling the spark gap, 
instead of increasing the intensity four times, as would be expected from 
the roentgenographic formula, only doubled it. It was further shown that 
the pastille measurement corresponded to the biological effect on the skin. 
Thus the formula for measurement of unfiltered X-ray intensity in radio¬ 
therapy is: 

Spark Gap (voltage) X Milliamperage X Time 
Distance X Distance 

Having established an equation using the factors necessary to produce 
a certain biological or pastille effect, the result could be repeated on dif- 






600 


X-RAY THERAPY 


ferent patients, using the same or different machines. It was also found 
that by using this formula other factors could be substituted, and the 
same results obtained by arithmetical computation, and that three factors 
being known, the fourth could be computed. 

In pastille readings with the Holzknecht radiometer H-l is used as 
the unit of measurement, and represents one-fifth of the amount of radia¬ 
tion necessary to produce an erythema. Four times this (H-4) is the 
amount necessary to depilate the scalp without causing a permanent 
alopecia, and is the so-called “skin unit.” 

The standard formula for 1 skin unit, using a 3-inch spark gap, 3 
milliamperes, 4-minute time, at 8-inch distance, is: 

3X3X1 36 


8X8 64 

Any, or all factors may be changed, and given any three factors, the 
fourth may be obtained by the following rules. 

1. To determine milliamperage, spark gap, or time, the standard 
formula is used as the dividend. 

2. To determine distance or amount the standard formula is used 
as the divisor. 

Examples: 

What would be the time necessary for one unit, using a 6-inch gap, 
3 milliamperes, and 8-inch distance ? 

6 X 3 X ? 18 

8X8 64 

36 18 36 64 

-1-= — X — — 2 (minutes time needed) 

64 64 64 18 

It therefore follows that if the spark gap be doubled, and the time 
reduced one-half, the same amount of radiation will be produced. 

What spark gap would be necessary to produce 1 skin unit using the 
following factors: 3 milliamperes, 2 minutes, 8-inch distance? 

? X 3 X 2 6 

8X8 64 

36 6 36 64 

- \ -= — X — = 6 inches (spark gap required) 

64 64 64 6 





COMPUTING X-RAY INTENSITY OR DOSAGE 


601 


What would be the distance required to produce 1 skin unit, using 
the following factors: 3-inch spark gap, 3 milliamperes, 16 minutes? 

3 X 3 X 16 144 


D X D D 2 

144 36 144 64 / 256 

-i-=-X — ~\ -— 16 inches (distance) 

D 2 64 D 2 36 | D 2 

What would be the amount of radiation produced using the following 
factors: 6-inch gap, 3 milliamperes, 5 minutes, at 8-inch distance ? 

6X3X5 90 


8X8 64 

90 36 90 64 5 

-;-== — X — = — = 2% (skin units) 

64 64 64 36 2 

The following experiment was also done: 


Experiment Showing Time for One Unit 


Milliamperes 

Spark Gap 

Distance 

Time 

Skin Units 

(D 

3 

3 

8 

2 

I 

(2) 

3 

6 

8 

2 

1 

(3) 

6 

3 

8 

2 

1 

(4) 

3 

6 

16 

2 

4 


Erom the above experiments the following rules can be deduced: 

1. Doubling the spark gap or milliamperage doubles the amount or 
halves the time. 

2. Doubling the distance quarters the amount or quadruples the time. 

Filtered Radiation 

According to the pastille measurement, twice the amount of radiation, 
or 2 y 2 skin units, is required to produce an erythema when a filter is 
interposed. 

In the estimation of filtered intensity or dosage, the method differs, 
for while in unfiltered radiation there is one standard formula, in filtered 
there must be a formula for each thickness of filter employed. Further 
divergence from the photographic formula is noted in that the intensity 














602 


X-RAY THERAPY 


varies inversely with the distance instead of with the square of the 
distance. 2 

Also the time factor in filtered radiation differs from that of un¬ 
filtered in its action on the skin and pastille, for while in the latter 
doubling the time doubles the amount, in filtered radiation the increase 
in the pastille reading depends on the spark gap or voltage in connection 
with the filter employed. When a 6-inch spark gap is used and the time 
required for 1 filtered unit is doubled, the reading is 1% filtered units 
instead of 2. Repeating this process advances the reading % filtered 
unit. When a 7-inch gap is employed, doubling the time produces l 1 /^ 
filtered units, and the reading then advances at the rate of ^4 filtered unit 
for each exposure. Using an 8, 9 or 10-inch gap advances the reading 
at the rate of % for each exposure until 2 filtered units have been reached, 
and then advances at the rate of % filtered unit. 

The only exception to this rule is where 5, 6, or 7 millimeters of 
aluminum are used, when doubling the time advances the reading to 2, 
and then at the rate of % for each exposure up to 3 filtered units. 

The following formulae have been established for the different thick¬ 
nesses of aluminum filter employed. The thickness of these filters ranges 
from % to 7 millimeters. 


Formulae for Aluminum Filter 


Millimeters of 
Aluminum 

Spark Gap 

Milliamperes 

Distance 

Inches 



Time 

Standard 

Formula 

i 

9 

5 

10 

0 min. 42 sec. 

63 

20 

i 

9 

5 

10 

1 

u 

06 “ 

99 

~2CT 

1 

9 

5 

10 

1 

u 

54 “ 

171 

20 

2 

9 

5 

10 

2 

u 

20 “ 

21 

2 

3 

9 

5 

10 

2 

u 

34 “ 

231 

'W 

4 

9 

5 

10 

4 

u 


18 

5 

9 

5 

10 

7 

{( 


63 

~2~ 

6 

9 

5 

10 

7 

a 


63 

~ 

7 

9 

5 

10 

7 

« 


63 

~2~ 


3 This fact Las been disputed, and is still a matter of contention between the 
physicists and the author of this paper. While, from the physicists’ point of view, 
their contention, based on the action of the ray on the photographic plate and the 
ionization chamber is correct, from the biological standpoint and the experience 
gained by the use of the formula for the past six years by many radiotherapeutists, 
its correctness up to 110,000 volts and 7 millimeters of aluminum has been fully 
established. 











COMPUTING X-RAY INTENSITY OR DOSAGE 603 

To illustrate the difference in reading when the time necessary to 
produce one filtered unit is increased, the following table from Witherbee 
and Remer’s original article is copied—in each instance the filter being 
3 millimeters aluminum. 


Differences in Reading Shown 


Spark Gap 

Milliampcras 

Distance 

Time 

Filtered Units 

6 

5 

10 

3 min. 51 sec. 

1 

6 

5 

10 

7 min. 42 sec. 

P/4 

6 

5 

10 

11 min. 33 sec. 

iy 2 

6 

5 

10 

15 min. 24 sec. 

i% 

6 

5 

10 

19 min. 15 sec. 

2 

7 

5 

10 

3 min. 18 sec. 

i 

7 

5 

10 

6 min. 36 sec. 

• iy 2 

7 

5 

10 

9 min. 54 sec. 

l 3 /4 

7 

5 

10 

13 min. 12 sec. 

2 

7 

5 

10 

16 min. 30 sec. 

2 %, 

7 

5 

10 

19 min. 48 sec. 

2y 2 

7 

5 

10 

23 min. 6 sec. 

2 3 / 4 

7 

5 

10 

26 min. 28 sec. 

3 

8 

5 

10 

2 min. 53 sec. 

1 

8 

5 

10 

5 min. 46 sec. 

IV 2 

8 

5 

10 

8 min. 39 sec. 

2 

8 

5 

10 

11 min. 32 sec. 

2%, 

8 

5 

10 

14 min. 25 sec. 

2% 

8 

5 

10 

17 min. 18 sec. 

2% 

8 

5 

10 

20 min. 11 sec. 

3 

9 

5 

10 

2 min. 34 sec. 

1 

9 

5 

10 

5 min. 8 sec. 

u / 2 

9 

5 

10 

7 min. 42 sec. 

2 

9 

5 

10 

10 min. 16 sec. 

2 y 4 

9 

5 

10 

12 min. 50 sec. 

2 y 2 

9 

5 

10 

15 min. 24 sec. 

2% 

9 

5 

10 

17 min. 58 sec. 

3 

10 

5 

10 

2 min. 19 sec. 

1 

10 

5 

10 

4 min. 38 sec. 

. u / 2 

10 

5 

10 

6 min. 57 sec. 

2 

10 

5 

10 

9 min. 16 sec. 

. 21/4 


The mathematical computation for filtered radiation differs some¬ 
what from that of unfiltered, in that it is always necessary first to find 
the time required for 1 filtered unit, and this must be multiplied by the 
number of times this exposure must be repeated to obtain the desired 
amount. 














G04 


X-RAY THERAPY 


Examples: 

What would he the time required to give an exposure of 2 filtered 
units, using the following factors: 7-inch spark gap, 4 milliamperes, 12- 
inch distance, 1 millimeter aluminum filter. 


7X4 

12 


28 

12 


171 

The standard formula for 1 millimeter of aluminum is-- 

20 


28 


First find the time required hy dividing the standard formula by —. 

12 

171 28 171 12 . , , 

—-—•———= —— 3%, or 3 minutes and 40 seconds, time re- 

20 1 2 20 2a . i (, n -t. i .. 

quired lor one filtered unit. 


Referring to the above table we find that 4 times this amount is neces¬ 
sary to produce 2 filtered units, therefore 14 minutes and 40 seconds is 
the required exposure. 

Unfiltered Treatment. —In dermatology the X-ray has long been a 
routine measure, and it was in this branch of medicine that it had its 
first principal application. In some instances it is curative where other 
methods have failed. In others, it is a valuable adjunct to medication. 

The advantage of cleanliness, convenience, and absence of pain, and 
the elimination of the use of irritating and offensive ointments, usually 
commend it to the patient. “Often there are economic reasons which 
make its use more practical, especially for the wage-earner.” 

The method used in dermatological work is that of unfiltered radia¬ 
tion. A spark gap of 6 to 7 inches, a current of 2 to 3 milliamperes, with 
a target skin distance of 8 inches, usually gives the best results. The 
time and number of exposures must of necessity vary with the nature 
of the condition under treatment—from one-tenth of an erythema ex¬ 
posure, when the pathological condition is of an acute or subacute inflam¬ 
matory nature, to two or more erythema exposures, when it is of the 
granulomatous or neoplastic type. 

The methods employed in the treatment are the intensive, the semi- 
intensive, and the fractional. 

Intensive Treatment .—Single exposures of from 1 to 2^ skin units 
repeated at four to six-week intervals. 

Semi-intensive Treatment .—Exposures of from % to % skin unit 
repeated every two or three weeks. 

Fractional Treatment .—% to of a skin unit repeated, semiweekly 
if the % S. U. is employed, and weekly if the % S. U. is used. 

Not only is there a pathological indication for the intensity of ex¬ 
posure, but there is also a technical condition, that is, the character of the 



COMPUTING X-RAY INTENSITY OR DOSAGE 


605 


skin, the age of the patient, etc. Also, the entire body should not be 
exposed at one time, owing to too great a systemic reaction, acidosis, and 
too great a reduction of the lymphocytes to insure a normal recovery 
before the time of subsequent exposure. 

In generalized conditions such as psoriasis, generalized eczema, and 
mycosis fungoides, exposures are preferably given three times a week, 
allowing a day to elapse between each exposure. The entire body is 
divided into three areas, and these again subdivided. Eor the first ex¬ 
posure the head and arms are radiated, second, the trunk and buttocks, 
and third, the legs and thighs. 

The head is divided into five areas, as in the Adamson-Kienbock 
method for tinea of the scalp; the arms, forearms, and hands into- six 
areas each, three flexor and three extensor; the trunk into eight areas, 
four ventral and four dorsal; the buttocks, one for each buttock; the legs 
and thighs into six areas, three anterior and three posterior. 

The exposure given is % skin unit to each area of the scalp once a 
week until four exposures have been given. Treatment is then dis¬ 
continued for four weeks, and if necessary a second series is given, and 
after a rest period of four weeks may be repeated if the condition 
requires. 

To each of the areas of the body y± skin unit is given each week 
until the lesions have disappeared, the treatment usually being concluded 
in from four to eight weeks, depending on the severity of the case. If it 
is impossible to follow the above method, which is the ideal one, the body 
is divided into two general areas, and exposures made twice a week, 
employing y 8 skin unit for each area of the body instead of %. 

When Unfiltered Radiation May Be Used 

Rosacea, Per Se. —This does not respond to radiation, although the acne 
which is usually an accompaniment of this condition will be benefited. 

Lichen Planus. —Favorable results are practically always obtained in 
the treatment of lichen planus by irradiation, but on the character of the 
lesions will depend the technic to be employed. The influence of the ray 
on the severe pruritus which accompanies this condition is marked, fre¬ 
quently after the first treatment. 

When the disease is generalized, the technic given for generalized 
diseases should be followed. In the acute or chronic type *4 skin unit 
at weekly intervals should bo administered. Usually involution begins 
after one or two exposures, and a cure is effected after from 6 to 10 
irradiations. In the hypertrophic type of the disease the % skin unit 
is not sufficient to bring about the desired result, so that a suberythema 
exposure of 1 skin unit is best employed, to be repeated every four weeks. 

Small circumscribed patches of ordinary lichen planus respond to frac- 


606 


X-RAY THERAPY 


tional doses of y 4 skin unit administered weekly, the individual lesions 
being isolated, and the surrounding normal skin protected with lead rubber 
or lead foil. 

In the verrucous type, owing to the marked hyperkeratosis, intensive 
treatment should he given; iy 4 to 1% skin units should be administered, 
and repeated in four to five weeks, if necessary. Care must be taken to 
protect fully the surrounding normal skin with lead foil. While usually 
unfiltered ray is effectual in the verrucous type, involution may frequently 
be hastened by using a filter of 1 millimeter aluminum, an exposure of 
2 filtered units Being given. 

Psoriasis. —It is doubtful if there is any method of treatment that can 
compare in favorable results with X-ray in the treatment of psoriasis. 
The cleanliness of the method, as compared with the use of ointment, 
especially chrysarobin, appeals to the patient, and also from an economic 
standpoint it is of value, hut it must be borne in mind that the disease 
is incurable, and that recurrences are bound to appear sooner or later, 
the time varying from a few weeks to a year. In one*case in the author’s 
practice there was no recurrence for two years. 

Occasionally there are cases which will not respond to radiation, new 
lesions appearing in areas which have shown improvement, and are under 
treatment. In a case where the disease is to he influenced by radiation, 
it will disappear under 6 to 8 treatments of fractional exposures of 
y 4 skin unit given weekly, an improvement being noted after two or 
three exposures. If the disease shows no improvement after 8 to 10 ir¬ 
radiations, it is well to discontinue the X-ray treatment. 

When the disease is general, the method suggested for generalized 
diseases should be followed. Should the scalp he involved, no more than 
a total of y 2 skin unit, divided into weekly exposures of % skin unit 
each, should be given. One course should he sufficient to cure, hut if 
not, there should be an intermission of four weeks, after which the treat¬ 
ment may he repeated. The five points used in tinea tonsurans are used 
in treating the scalp, although accurate measurements are not made. 

If the lesions are of long standing, and there is much thickening, good 
results may often he obtained by the use of 1 millimeter of aluminum 
filter, y 2 filtered unit being administered every one or two weeks. 

Recurrences .—While it is permissible to treat recurrences in the 
manner above outlined, judgment must he exercised in the use of the ray, 
and it must be borne in mind that too prolonged radiation, even in frac¬ 
tional doses, may cause atrophy of the skin and underlying tissues, which 
will be followed by telangiectasia. 

Psoriasis of Face .—The same technic should be followed in this con¬ 
dition as in acne of the face. Psoriasis of the hands and feet yields 
to the same technic as psoriasis of other parts of the body. It is often 
necessary to expose both the dorsal and palmar surfaces. If both hands 


COMPUTING X-RAY INTENSITY OR DOSAGE 607 


are affected, it is best to irradiate each hand separately, and, in exposing 
the palmar surface, to measure from the highest point, that is, the thenar 
eminence. Each foot should also be exposed separately. 

Psoriasis of Nails .—This condition is more resistant to irradiation, 
and frequently ten or twelve treatments are necessary to produce satis¬ 
factory results. The skin about the nails should be protected, as in 
paronychia or similar nail conditions. 

Eczema. —Probably in no dermatological condition has X-ray a wider 
therapeutic range or greater value than in eczema, both in the acute and 
chronic types. As early as 1900 it was used with beneficial results; but, 
with the more definite knowledge of the conditions which are now classed 
under the general heading of eczema, its use and application have become 
more general and efficacious. 

In the earlier history of the X-ray for this condition it was thought 
that, permanent clinical cures could be effected, but this has been found 
to be erroneous. There are apt to be recurrences, the time of recurrence 
varying with the different causes and types of the disease. 

The response of eczema to the ray is usually very prompt, frequently 
being manifest after the first or second exposure. Among the early symp¬ 
toms to be relieved is the intense pruritus. 

The intensity of the exposure of Koentgen ray in the therapy of 
eczema depends upon the principle that the more acute the inflammatory 
process, the less the intensity of exposure required; and, conversely, the 
more chronic the process, that is, the types associated with thickening, 
namely, acanthosis and connective tissue hypertrophy or hyperplasia, the 
greater the intensity required to cause absorption. 

Technic .—When the condition is generalized the body should be divided 
into areas and treated as previously described. When the lesions are 
isolated, each lesion should be treated individually, the surrounding healthy 
skin being protected by lead. For mild acute or subacute types, exposures 
of from to % unfiltered skin unit should be made every three to seven 
days. For the more chronic types, exposures of from % to % of an 
unfiltered skin unit should be administered every two or three weeks. 

Frequently in the use of the unfiltered ray, especially in the indurated 
types, absorption will be slow. The prolonged use of the X-ray, which 
may be necessary, may produce atrophy and subsequent telangiectasia. 
In such cases the use of filtered exposures is indicated, the amount of 
thickening and the penetration of the ray desired determining the thick¬ 
ness of the filter to be employed, that is, from 1 to 3 millimeters of 
aluminum. The exposure should be ^ to 1 filtered unit administered 
every seven to fourteen days. In the mild acute and subacute types, from 
six to ten exposures will usually produce a clinical cure; in the more 
chronic types, especially where there is much thickening, a longer time 
usually will be required. 


608 


X-RAY THERAPY 


The intensity of the exposures and the intervals between the exposures, 
whether filtered or unfiltered, will depend upon the clinical status of each 
individual case. 

The employment of X-ray in eczema does not by any means prohibit 
the use of drugs wdiich may be of value in connection with the ray, such 
as zinc, boric acid, calamine, bismuth, mild preparations of ammoniated 
mercury, etc. (see complete list of permissible and contra-indicated drugs) 
in the form of powder, lotions, pastes or creams, as indicated. 

Lupus Vulgaris. —Although opinions differ regarding the results ob¬ 
tained in the treatment of lupus vulgaris by irradiation, in properly 
selected cases its value cannot be overestimated. In the atrophic type 
of the disease the ray has little or no effect. Xot only will satisfactory 
results not be obtained, but the prolonged treatment that is necessary 
will result in injury to the skin and underlying tissues. It is in the 
hypertrophic and ulcerative type that X-ray is applicable, and in these 
types the results will prove not only beneficial, but highly gratifying. 

Technic .—The intensive or suberythema method should be employed, 
rather than the fractional, and, as the disease occurs at all ages and af¬ 
fects various parts of the body, on the age of the patient and location of the 
lesions must depend the intensity of the exposure. Erom y 2 skin unit 
in children to from 1 to 1% skin units in the case of adults should 
be administered and repeated at intervals of from four to five weeks. 
It is wise to begin with exposures of lesser intensity (y 2 to 1 skin unit) 
and, if not followed by improvement, to increase the amount of radiation. 
An erythema should be avoided, if possible, particularly when the lesion 
is situated on the face. However, if the condition does not respond to 
suberythema exposures, the disease warrants producing an erythema, even 
.though a subsequent atrophy and telangiectasia may result. In irradiat¬ 
ing it is important to expose beyond the border of the lesion, so that 
from % to % inch of normal skin is included in the field irradiated. 
The surrounding normal skin should be protected by lead. There may 
be recurrences, and these should be treated in the same manner as the 
original condition. 

Lupus Erythematosus. —Irradiation in this disease is unsatisfactorv 
and is not advised. While in the early inflammatory stage, beneficial 
results may be obtained, later there is an “end result” of a chronic in¬ 
flammatory process, with atrophy and telangiectasia. If treatment is under¬ 
taken, the fractional method of % skin unit at weekly intervals should 
be employed, and if after four or five treatments there is no improvement, 
a change of technic is advised, administering from 1 to 114 skin units 
every four to five weeks. 

Mycosis Fungoides. —Although mycosis fungoides is incurable, 
marked relief can be afforded, a temporary clinical cure effected, and the 
life of the patient prolonged, by X-ray. There will always be recurrences, 


COMPUTING X-RAY INTENSITY OR DOSAGE 


609 


and the disease will ultimately prove fatal. One of the marked symptoms, 
the almost intolerable pruritus, can be controlled and is among the first 
symptoms affected. Mycosis fungoides presents its own indication for 
the frequency and intensity of the exposures. When the disease is gen¬ 
eralized, particular caution must be exercised in the treatment, as the 
disease seems to be extremely sensitive to X-ray, and the patient par¬ 
ticularly susceptible to systemic reaction. 

Technic .—In undertaking the treatment it is well to begin with ex¬ 
posures of small intensity and, if well tolerated, to increase the amount 
after two or three exposures have been administered. In the prefungoid, 
non-infiltrated stage, especially if the condition is widespread, it is best 
to begin with exposures of % skin unit, repeated at weekly intervals. 
After three or four weeks this may be increased to % skin unit weekly. 
Too prolonged radiation should not be given as an immunity may be es¬ 
tablished. In such a case an interval of rest should be allowed, after which 
treatment may be resumed with beneficial effect. If the disease is not 
generalized, but consists of only isolated, non-infiltrated plaques, the 
plaques should be irradiated individually, the surrounding healthy skin 
being protected, and the same intensity of exposure being employed as 
when the disease is generalized. 

MacKee advises a differential blood count every two weeks, and if there 
is an increase in the lymphocytes or if there is any evidence of toxemia, 
that irradiation be temporarily discontinued. 

In the fungoid stage of the disease, fractional treatment will not suf¬ 
fice, and suberythema exposures of 1 skin unit every four weeks should 
be administered. If, after the first irradiation, there is not marked^ im¬ 
provement, the intensity may be increased to 1% to 1% skin units, re¬ 
peated when the erythema has subsided. Although generally responding 
to unfiltered radiation, occasionally better results can be obtained by 
the use of a filter, especially if the tumor has attained a considerable size. 
Using a filter of 3 millimeters of aluminum, an exposure of from iy 2 
to 2 filtered units should be administered and repeated in four weeks, if 
necessary. 

In severe cases, and in the late stages of the disease, when the condi¬ 
tion may be regarded as systemic, Jadassohn advises the following technic: 
The body is divided into six areas, and using an 8-inch spark gap, 5 
milliamperes, and a filter of 3 millimeters of aluminum, J filtered unit 
is administered each day for six days, one area being irradiated at each 
exposure. A rest period of four days is then allowed, following which a 
second series of irradiations is given, again followed by a rest period 
of four days and a subsequent third series of treatments. Jadassohn 
claims for this method that not only is there no deleterious systemic 
reaction, but, on the contrary, there is an appreciable improvement in 
the disease itself and in the general health of the patient. 


610 


X-RAY THERAPY 


Tinea Tonsurans and Favus. —No other method is as prompt and 
efficacious in the treatment of this common and disagreeable condition as 
is radiation. In crowded cities, where a large number of children are 
affected, the disease becomes not only a nuisance, but also an economic 
problem. Unless a complete depilation is accomplished, a cure without 
recurrence cannot be expected. In many instances, but one or two isolated 
patches may be found, but even in these it is imperative to depilate the 
entire scalp, for if only the single patches are treated, the falling hair 
will affect healthy areas, and ultimately a complete depilation will be 
necessary. 

By employing the Adamson-Kienbock method of measurement of 
the scalp, and using the Coolidge tube and interrupterless transformer, 
an entire scalp can be depilated in from three-quarters to one hour. 

Tinea .—A marker for the measurement of the scalp has been devised 
by Dr. George Andrews, which permits of accurate measurement with a 
marked saving of time. While in the hands of a competent operator this 
method of treatment is simple, and the results accomplished are gratifying, 
a word of warning should be sounded, for unless there is absolute ac¬ 
curacy in every detail, there is great danger of permanent alopecia, if not 
more serious results. 

Before irradiation it is most important to ascertain whether or not 
the patient has had any previous application of the ray to the scalp, or 
has been using any irritating drugs, such as salicylic acid, iodin, mercury, 
etc. If any such drug has been used, it is best to delay treatment for at 
least two weeks after the last application, as failure to do this may re¬ 
sult in a radiodermatitis, or permanent alopecia. It must also be re¬ 
membered that no irritating application should be used for two weeks 
following the treatment. 

It is inadvisable to attempt to administer treatment to a child under 
four or five years of age, owing to the difficulty of keeping it quiet. There 
are, of course, exceptions, as often younger children can be irradiated 
successfully. 

The hair should be clipped close. This not only permits of easier 
marking, but allows the full amount of ray administered to reach the scalp. 
(The hair, if thick, filters out a definite amount of ray.) Also, all scabs 
and crusts should be softened and removed with vaselin or a non-irritat¬ 
ing soap and water. 

Technic; Marking .—Measure from the anterior to the posterior hair 
line, subtract 10, divide the remainder by 2. The quotient will give the 
number of inches inside the anterior and posterior hair lines, that is, 
the frontal and occipital points, and the measurement between these two 
points should be 10 inches. A point midway between these in the median 
line will mark the crown point. Measure downward from the crown point 
5 inches on each side for the parietal point. There then should be exactly 


COMPUTING X-RAY INTENSITY OR DOSAGE 611 


5 inches between all points. The circumference of the head should meas¬ 
ure 20 inches. 

For example, suppose the distance from hair line to hair line is 14 
inches. Subtract 10, which leaves 4. Divide this by 2, which gives 2 
inches, the distance from the anterior and posterior hair lines. The 
frontal point will be 2 inches posterior to the anterior hair line, and the 
occipital point 2 inches anterior to the posterior hair line. The distance 
between these two will he 10 inches. The marker above referred to obvi¬ 
ates the necessity of making these measurements. 

In some cases the distance from hair line to hair line will be found 
to he exactly 10 inches. In such an event, the anterior and posterior hair 
lines will coincide with the frontal and occipital points. 

Again, it occasionally happens that the circumference of the head will 
measure 10 or 21 inches. In such cases % inch should be added or sub¬ 
tracted from the 5 inches between points. 

Lines are drawn joining each point, which will divide the scalp into 
four triangles. This will be found of great advantage in determining the 
angle for each point of exposure, which must be at right angles to every 
other point. 

Exposure .—Having determined the exact points, the procedure is as 
follows: with the child lying on the hack, the head is turned to one side 
so that the line of the chin is on a level with the shoulder. The face be¬ 
low the hair line is covered with lead foil. An epilating exposure is 
given to the parietal point. The head is then turned to the other side and 
the opposite parietal point is exposed. Lying with the face upward and 
shielded with lead foil, the frontal point is next exposed. Then with 
the child lying on the abdomen, and resting on the chin, the crown point 
is exposed. The head is then tilted forward so that it rests on the fore¬ 
head, and the occipital point is irradiated. Lead foil is placed over 
the back below the hair line. 

Although various distances and other factors are used, the following, 
used at the Vanderbilt Clinic, will be found convenient: spark gap 6 
inches, 3 milliamperes, 6^-inch distance, and 1% minutes’ time. This 
will give 1 skin unit, an exposure sufficient for epilation. 

At approximately the end of the third week, the hair will begin to 
fall, and the scalp will he depilated at the end of the month. The hair 
will begin to grow again in from one to two months. In from four to five 
months it will have entirely returned. If there is not a new growth of 
hair at the end of six months, there will be permanent alopecia. 

After a scalp has received treatment it is well to wash the head three 
or four times a week with soap and water, and, when the hair has fallen, 
to use a mild parasitic ointment. A linen cap should be worn during 
the time defluvium occurs. 

All fallen hair should be burned to prevent infection of others. 


612 


X-RAY THERAPY 


Recurrence is unusual, but if there should be a reinfection, a second 
depilation should not he done for at least five or six months. 

Favus .—This condition is more resistant, and it is frequently neces¬ 
sary to depilate a second, or even a third, time before a complete cure 
is effected. The same technic is employed as in tinea tonsurans. 

Blastomycosis and Actinomycosis. —Irradiation probably is superior 
to any other form of treatment for both these rather uncommon condi¬ 
tions. Where the lesions are situated on the skin, unfiltered radiation will 
give sufficient penetration to eradicate the condition, but if the deeper tis¬ 
sues are involved, better results will doubtless he obtained if a filter of 
aluminum of from 1 to 3 millimeters is used, depending upon the depth 
of the lesion beneath the surface. 

In superficial lesions from one to three intensive exposures of to 
2 skin units are given at intervals of from four to six weeks. Hot in¬ 
frequently a single treatment is sufficient to cause disappearance of the 
disease, but even in such a case, a second exposure is advisable as a pro¬ 
phylactic measure. 

In the treatment of lesions situated in the deeper structures, 2 to 2^4 
filtered units should be administered. 

Pruritus. —The antipruritic action of the X-ray is often remarkable 
in dermatological conditions. This is especially true in the pruritus of 
eczema, psoriasis, and lichen planus, the severe itching often being 
relieved before any manifestation of involution of the disease. This 
may be, or probably is, due to the effect on the terminal nerve 
filaments. 

Pruritus Ani et Vulvae. —Satisfactory and even brilliant results are 
obtained by irradiation, and in practically every case at least temporary 
relief can be obtained. This relief will last from a few months to a year 
or more, and in a proportion of the cases will be permanent after one 
course of radiation. Treatment should not be instituted until all pos¬ 
sible causes have been investigated and eliminated. When the anus is the 
only site of pruritus, the patient should lie on the abdomen, holding the 
buttocks apart with the hands. If, for any reason, this is impossible, ad¬ 
hesive strips may be used. When both the anus and vulva or scrotum 
are involved, the patient lies on the back, the knees and thighs flexed. 
In women, the region is divided into two areas, and two exposures are 
made, first centering the tube at the anterior part of the vulva, and then 
centering it at the anus. The thighs and portions not being exposed should 
be protected with lead foil. 

If the scrotum is involved, it will be necessary to ray the anterior 
and posterior surfaces separately. To expose the anterior surface, the 
scrotum is allowed to rest on a sandbag placed between the thighs, the 
penis being held on the abdomen. Lead foil is used to protect all sur¬ 
rounding skin not being irradiated. In irradiating the scrotum, care 


COMPUTING X-RAY INTENSITY OR DOSAGE 613 

must be exercised to avoid, if possible, producing 1 a temporary 
sterility. 

There are two methods of treatment, fractional and intensive. If the 
latter is employed, 1 skin unit should be given every four weeks. It is 
neither necessary nor advisable to produce an erythema. This method is 
not advised, and better results are usually obtained by the fractional 
method of treatment. One-quarter skin unit is given weekly until a total 
of 2 skin units has been given, if a satisfactory result has not been ob¬ 
tained before. The author has obtained the best results by the following 
method. 

The first week an exposure of y 2 skin unit is given; the second week 
i skin unit; and for the third, and subsequent exposures, % skin unit, 
given weekly until a total of 2 skin units has been administered. If at 
the end of six treatments no improvement has taken place, it is best to 
discontinue the treatment by X-ray. 

Recurrences should be treated in the same manner as the original 
condition. 

Keloid. —The results obtained in the treatment of keloid by X-ray 
are in most instances very gratifying. The earlier the treatment can be 
instituted after the development of the keloid, the more satisfactory will be 
the result, and the less treatment required. 

In organized and thickened scars, the treatment is necessarily of long 
duration, sometimes a year being required if a good cosmetic result is to 
be obtained. In irradiating this condition it is important that an erythema 
should never be produced. 

Technic .—The normal skin must be protected to the very edge of 
the keloid. On beginning the treatment, it is advantageous to cut from 
lead foil a pattern outlining the lesion. This is kept for the individual 
case, and affords a means of accurate measurement of the improvement. 

Where the condition is recent, unfiltered ray is used, and a suberythema 
exposure of 1 skin unit is administered every four or five weeks. When 
the condition is of long standing, or is fibrous in character, a filter of 
from 1 to 3 millimeters of aluminum may be used to advantage, and an 
exposure of from l 1 /^ to 1 y 2 filtered units administered every four to 
five weeks. 

In the negro it is particularly important that no more than a sub¬ 
erythema exposure be given, as repeated erythemas are likely to result 
in depigmentation. 

Dermatitis Papillaris Capillittii or Acne Keloid. —In the earlier or 
papular stage, unfiltered ray may be employed, and the disease aborted, 
suberythema exposures of 1 skin unit being given every four weeks. 

In the later stages, where the keloidal condition has developed, better 
results will be obtained by employing a filter, the technic being the same 
as for keloid. 


G14 


X-RAY THERAPY 


Epithelioma.— In the basal-cell type of epithelioma, cures are effected 
in about 95 per cent of the cases, and recurrences are rare if the amount 
of radiation has been adequate. 

Technic .—Curettage of the growth before radiation is advisable in 
order to remove the hard pearly border which is usually present, as the 
removal of this permits the ray to penetrate more deeply and more 
effectively. The area is covered with a piece of lead foil in which an 
opening has been made sufficient to expose the lesion and from % to % 
inch of the normal surrounding tissue. This is necessary in order to 
affect the cells which may lie beyond the periphery of the lesion. The 
area is given 2 to 2 y 2 skin units. After ten days an erythema appears, 
which lasts from ten days to two weeks and gradually disappears, the 
time depending upon the severity of the erythema. The appearance of 
the erythema is an indication of the inhibition of the tissue exposed. As 
soon as the erythema, has subsided, which is an indication of the recovery 
of normal tissue elements (usually in from four to six weeks), a second 
exposure is given. If all evidence of the disease has disappeared, the 
second exposure should be of less intensity than the first, that is, from l 1 /^ 
to 1% skin units. If, however, there is still evidence of disease, the 
second exposure should be of the same intensity as the first. This usually 
is sufficient to effect a cure. Care must be exercised in the treatment of 
this condition, as too frequent or prolonged radiation will so inhibit the 
normal tissue, as well as the pathological, that a chronic third-degree 
radiodermatitis will result. If after a third or fourth irradiation a cure 
has not been obtained, it is best to employ some other means of treatment. 

The patient should be kept under observation for a year, and further 
treatment administered if .there is any sign of recurrence. 

Prickle-cell or Squamous-cell Epithelioma. —This condition may occur 
on the skin, mucous membrane, or mucocutaneous junction. If this type 
is recognized in the early stage, it may yield to radiation if promptly 
and intensively treated, but on account of its tendency to metastasize, if 
not diagnosed and irradiated early, the neighboring glands may-have be- 
come affected. 

The technic of this treatment is the same as that outlined for the basal- 
cell type, except that lesions on the vermilion border should be exposed 
to only 1% to 2 units, since the mucosa is more easily affected than is 
the skin. 

Unless there is marked improvement after the first treatment, surgery 
or electrocoagulation should be employed. This is especially true of 
lesions of the vermilion border, which are apt to be particularly diffi¬ 
cult to control, and which, from the arrangement of the lymphatics, show 
early metastasis to the submaxillary glands. 

Whether the lesion be treated by electrocoagulation or surgery, it is 
wise to expose the affected area and the submaxillary region to three or 


COMPUTING X-RAY INTENSITY OR DOSAGE 615 


four treatments of filtered radiation, the treatment being instituted im 
mediately after electrocoagulation or operation. 

It is best to expose three small areas on each side of the jaw, extend¬ 
ing from the symphysis mentis to beyond the ramus of the mandible, to 
1% to 2 filtered units every four weeks for three or four exposures. This 
is imperative if there is evidence of glandular involvement. 

Melanoma. —This condition can usually be caused to disappear after 
three or four intensive treatments with unfiltered radiation. If, after the 
fourth treatment, the condition persists, other means should be employed. 

It has been the author’s custom to apply the ray to three concentric 
areas having the lesion as their common center. In order to accom¬ 
plish this without danger of overlapping, three pieces of lead foil at 
least 6 inches square are used. In the first of these is made an open¬ 
ing just large enough to include the lesion. In the second, the opening 
is made to include the lesion and half an inch of the surrounding healthy 
tissue. In the third the opening should be made large enough to include 
the lesion and 1 inch or more of the surrounding tissue. The piece with 
the largest portal is first placed so that the lesion is at its center, and 
an exposure of 1 skin unit is given. All tissue except that in the area 
being treated should be covered by lead foil. The medium-sized portal 
is next placed around the lesion, and from % to % skin unit given. The 
smallest portal is then placed so as to expose only the lesion, and % to % 
skin unit is administered. 

In this way the lesion receives from 2 to 2% skin units, the amount 
given depending on the location of the lesion and the age of the patient. 

A second treatment is administered after the erythema has subsided, 
which will be at the end of five or six weeks, and a third and fourth ex¬ 
posure after like intervals. The patient should then report for observa¬ 
tion every month or two for one year, and further treatment be given if 
any tendency toward recurrence is noted. 

Acne. —Probably there is no condition which responds more favorably 
to X-ray treatment, nor in which more absolute technic is required, than 
acne. One must bear in mind, however, the danger of overexposure either 
in excessive individual exposures, or in prolonging the treatment to an 
excessive number of exposures. Properly selected cases, with accurate 
application of the ray, and proper constitutional treatment will result 
in a cure in about 95 per cent of the cases. The fractional method is 
employed. 

Technic .—The patient is placed in the prone position, with lead foil 
protecting the eyebrows, eyelashes, and hair. The head is turned to the 
side, the chin.being placed as nearly as possible on a line with the shoulder. 
With the anode centered over the highest point (usually the zygoma), 
exposures of % skin unit are given at weekly intervals to each side of 
the face, and, if there are numerous active lesions of the chin and fore- 


616 


X-RAY THERAPY 


head, an additional % skin unit is given to the front of' the face at bi- 
weekly intervals, the tip of the nose being used as a centering point. 
Usually sixteen exposures will he tolerated, and as a rule are sufficient 
to effect a cure. The first evidence of clinical improvement will not be 
noted until 1% to 1% units have been given, which will be in from five 
to six weeks. The skin must be watched carefully, and if there is marked 
dryness it is an indication for lessening the intensity of exposure, or dis¬ 
continuing treatment for one or two weeks. 

All cases should he carefully watched for the slightest evidence of 
erythema, and at the first suspicion of its appearance treatment should 
he suspended for one or two weeks. This can be determined by contrast 
in observing the area about the eyes where the protected and unprotected 
skin merge. Also the skin should he watched for evidence of atrophy, 
which will first be noted on the chin and about the corners of the mouth. 
At the slightest evidence of this, treatment should immediately he dis¬ 
continued. 

During X-ray treatment it is inadvisable to use any stimulating ap¬ 
plications, such as lotia alba, sulphur, etc., but an ointment of zinc oxid 
in unguentum aquse rosse may he applied to advantage. The affected 
part should he washed daily with soap and warm water. Careful regula¬ 
tion of the diet is important. Fried foods, pastry, candy, and all rich 
foods should he eliminated. The bowels should be regulated, making sure 
of a movement each day. The diet should be maintained for at least six 
months after the last treatment. 

If after five or six weeks satisfactory results are not obtained, or if 
the lesions are markedly indurated, it is well to use a filter of 1 millimeter 
of aluminum, administering y 2 filtered unit (see Filtered Ray) each week 
for two or three weeks, then y 2 filtered unit every two weeks for two treat¬ 
ments, and then % skin unit unfiltered. 

Cystic and Pustular Type .—The pustules should be evacuated and the 
routine treatment of % skin unit given weekly. In this type of acne good 
results are obtained by the use of vaccines in connection with X-ray 
treatments. 

When the chest and back are affected, the same procedure is advised, 
three areas being sufficient for the entire back. The anode is centered over 
the outer edge of each scapula for the upper back. For the lower back 
one exposure is used, the anode being centered over the spine at the level 
of the lower border of the ribs. 

Recurrences do occur, but only in a small percentage of the cases. 
They are usually mild and respond readily to a second course of radia¬ 
tion, the time required, and the amount of ray necessary being less. If 
a prompt response is not observed, it is unwise to persist. 

Sycosis Vulgaris. Probably no disease will tax the ingenuity and 
patience of the radiotherapeutist more than will sycosis, for the disease 


COMPUTING X-RAY INTENSITY OR DOSAGE 617 

will often prove most resistant, and it is frequently necessary to depilate 
in order to effect a cure. 

As it is sometimes not necessary to depilate, it is well to begin with 
fractional exposures of % skin unit once a week for five or six weeks. 
If, at the end of this time, there is no improvement, there remain two 
alternative methods. First, exposures of a filtered y 2 skin unit at weekly 
intervals may effect a cure. Second, depilation may be necessary. If the 
latter method is employed, extreme caution must be used in order to pre¬ 
vent a permanent alopecia. It is of equal importance that even a mild 
degree radiodermatitis should not result, as this would be followed later 
by atrophy and telangiectasia. In order to produce a defluvium, 5/16 skin 
unit should be given once weekly for four exposures. From one week to 
ten days after the last treatment the hair will usually fall. 

Technic .—When the disease is limited to the bearded region, ex¬ 
posures are given to five areas. The patient’s position is the same as in 
acne. 

1. Center just below the zygoma on each side. 

2. Center just below the angle of the jaw on each side of the neck. 

3. Tilt the head backward, and center just below the chin in the 
median line. Care must be used to prevent overlapping, and it may be 
advantageous to cover with lead foil or lead rubber the parts not being 
treated. It is imperative that no irritating drugs be used for two weeks 
before, during, or two weeks after, the treatment. 

When depilation is complete, a mild ointment of ammoniated mercury 
(3 per cent) may be used. 

In the treatment of sycosis of other hairy regions, such as pubis, 
axillae, eyebrows, etc., the exposures are the same. If the eyebrows are 
affected it is advisable to cover the eyelids with lead foil. 

Hyperidrosis and Bromidrosis. —Beneficial results can be obtained in 
this discomforting condition by X-ray treatment. It must be borne in 
mind that it is only the sweat glands which must be affected, and that 
under no condition must a complete atrophy of these glands be produced. 
Usually there is a decrease in the excessive secretion of the glands in a 
short time, and it is at this period that caution must be exercised in 
order to avoid carrying the treatment beyond the point of safety. 

Technic .—Either the fractional or suberythema method of treatment 
may be employed, at the discretion of the operator. If the fractional 
method is chosen, exposures of ^4 skin unit are administered every week, 
with a total of not over 1 skin unit in four weeks. If the suberythema 
exposure is employed, 1 skin unit, repeated in four weeks, is advised. 

If the hands are affected, each hand should be irradiated separately, 
the anode being centered at the highest point, that is, the thenar eminence, 


618 X-RAY THERAPY 

on the flexor surface, and at the metacarpal phalangeal junction for the 
extensor surface. 

In irradiating the feet each foot should be exposed, the plantar sur¬ 
face being divided into two areas, and the unexposed area being covered 
with lead foil. The dorsal surface is next exposed. Centering just 
posterior to the metatarsophalangeal articulation, *4 skin unit is ad¬ 
ministered to each area. 

In hyperidrosis of the axillae care must be taken to avoid too marked 
pigmentation, especially in the female, which may persist for several 
months and often cause much annoyance. If the fractional method is 
chosen, % skin unit weekly may he administered but if the suberythema 
exposure is given, it is suggested that % skin unit be given and repeated 
in four weeks. 

Bromidrosis, which is usually associated with hyperidrosis, can be re¬ 
lieved and frequently cured by the use of X-ray, the technic being the same 
as that outlined for hyperidrosis. 

Hypertrichosis. —Without doubt there is no condition which the radio- 
therapeut’st is more often called upon to treat than this. While treat¬ 
ment has often been undertaken, and while at present new technics are 
being developed both in the United States and in Europe, until more per¬ 
fect methods are developed, or the present experiments are more fully 
perfected, it should, in the author’s opinion, neither be advised nor under¬ 
taken. 

In order to produce a permanent alopecia it is necessary to cause a 
complete atrophy of the hair follicle. The sebaceous and sweat glands 
are less highly organized and more superficial. Therefore in producing an 
atrophy of the hair follicle, it necessarily follows that there will be pro¬ 
duced also an atrophy of these glands, with loss of elastic tissue, which is 
sure to be followed in from six months to a year by wrinkling and 
telangiectasia. This unfortunate result, not being immediate, gives no 
warning. Erom the medicolegal standpoint, neither a signed contract 
with the patient nor a warning of the untoward results which may follow 
will protect the radiotherapeutist from legal complications. 

When Filtered Radiation May Be Used 

Carcinoma. —Perhaps the greatest field for X-ray therapy, and cer¬ 
tainly the one that at present is holding the most widespread attention 
among physicians and laity alike, is that of carcinoma. More experi¬ 
mental and research work is being done in the effort to find a dependable 
cure for this disease than for any other condition, and surely no other 
field holds so many brilliant promises, and at the same time imposes such 
discouraging and unforeseen obstacles. There is no branch of pathology 
in which the individuality of each case is more clearly demonstrated, nor 


USE OF FILTERED RADIATION 


619 


in which cases, to all clinical appearances parallel, show greater diversity 
of results when treated in the same manner. 

Whether this is because of the resistance of the patient, the type of 
cancer, or the degree of malignancy of the growth, is not clearly under¬ 
stood, but it is universally recognized. Ewing recently gave the results 
of his experiments with X-ray on the cancers of two rats. As far as 
it was possible to determine by both macroscopic and microscopic examina¬ 
tion, the growths were identical in both animals, yet that of one was 
not destroyed by several times the. amount of ray necessary to cause the 
death of all cells in the other. This seems to indicate that some tumors 
are more resistant than others, and probably accounts for the widely dis¬ 
similar results in cases treated along parallel lines; and leads one to 
question the statement so positively made by certain of the foreign in¬ 
vestigators that the “lethal dose” for carcinoma is 110 per cent of an 
erythema dose. 

Many cases of carcinoma have been clinically cured by X-ray (and 
after five or more years have shown no evidence of recurrence). One such 
case is still well although the last treatment was given ten years ago. A 
better understanding of the methods of treatment and improved technic 
are giving a greater number of brilliant results, and warrant the hope 
that the problem may soon he solved. At the present time results are 
not sufficiently uniform to justify the contention of the most enthusiastic 
advocates that X-ray is the “last word” in the treatment of carcinoma, 
and that surgery should be discontinued in all cases. In inoperable con¬ 
ditions the use of the ray offers positive relief of the symptoms, probable 
prolongation of life, and perhaps regression and clinical cure. 

In operable cases probably the most efficient treatment, and that of¬ 
fering the greatest possibility of a happy outcome, consists in preopera¬ 
tive radiation to inhibit the tumor cells and to minimize the danger of 
dissemination by operative procedure; radical surgical removal of the 
tumor within two to three weeks; and postoperative radiation as soon 
after as possible in order to destroy any cells that may have escaped the 
surgeon’s knife. 3 

One of the greatest stumbling blocks in malignancy is the problem of 
metastasis. Cases in which the most gratifying results in the local lesion 
are obtained within a few months after operation frequently show wide¬ 
spread metastasis, especially to the hones. Preoperative radiation has 
seemed to reduce the likelihood of such an unfortunate outcome, and as 
surgeons begin to realize its advantage and employ it more widely, doubt¬ 
less a decided advance will be made. 

8 In order to permit the use of the ray both before and after operation, without 
loss of time, picric acid preparation of the surgical field is advocated, instead of 
the bichlorid of mercury and iodin preparation usually employed (see Contra-indi¬ 
cated Drugs). 



620 


X-RAY THERAPY 


Technic .—The method of treatment will differ according to the type 
of radiation used, that is, whether the older 110,000-volt machine or the 
newer 200,000-volt type is employed. 

Using the older method, the portals of entry for the ray are smaller 
in size, but more areas are irradiated. The section of the body in which 
the tumor is located is divided into small areas, 5 by 8 centimeters to 10 
by 12 centimeters (2 by 3 inches to 4 by 5 inches), a border of % to % 
inch being left between the areas to prevent overlapping. These areas 
usually include the entire circumference of the body. Lead, or other 
suitable protective material, is so placed that the X-ray can reach only 
the area to be irradiated. These portals are then exposed in rotation to a 
maximum suberythema filtered exposure, the ray being directed through 
each portal toward the lesion, thus producing a cross-fire effect, which 
enables the maximum amount of ray to reach the tumor without causing 
destruction of the superficial tissues. The operator must be warned 
against too much cross-firing, as it is possible to produce a deep-seated 
necrosis without any apparent radiodermatitis. 

The length of exposure of each area must vary with the factors used 
(spark gap, milliamperage, distance, filter) ; but not over 2 to 2% filtered 
units (four-fifths of an erythema exposure) should be given. Thus, using 
a 9-inch gap, 5 milliamperes, 25 centimeters’ (10 inches’) distance, 3 
millimeters of aluminum (filter), 7% to 10 minutes’ treatment can be 
given to each area. 

The number of areas irradiated at each session will vary with the 
total number of portals to be exposed, and with the condition of the pa¬ 
tient. Four to six areas are usually well borne, and sometimes more 
may be tolerated. Wherever it is possible, the total number of portals 
should receive treatment within a week’s time, exposures being made on 
alternate days. 

This procedure is repeated every four to five weeks for three series, 
and again eight weeks after the third course of treatment. If progress 
has been satisfactory, radiation is discontinued, but the patient is kept 
under observation for one or two years, and at the first unfavorable indi¬ 
cation, treatments are resumed. 

Too long-continued treatments will lead to atrophy of the subcutaneous 
tissues, telangiectasia, and even necrosis, so that, except in those cases 
where the gravity of the situation demands heroic measures, too many 
series should not be given. 

In employing the 200,000-volt technic, a “depth dose” of 110 per 
cent of an erythema exposure is administered to the growth. The number 
and size of portals used, and the amount of exposure given to each, varies 
with the location of the tumor. 

Sarcoma. —The estimated “lethal dose” when the 200,000-volt technic 
is used is 70 per cent to 80 per cent of the erythema exposure; this in 


USE OF FILTERED RADIATION 


621 


contrast to the 110 per cent needed to destroy carcinoma. Therefore it 
would seem that a cure of this condition by X-radiation should be easy 
and certain, and that the most hopeful prognosis might safely be given. 
Unfortunately, such is not always the case, and a guarded prognosis must 
be made, because, as in carcinoma, the degree of malignancy of the growth, 
and its individual resistance to irradiation, cannot be accurately estimated. 
In general, the round and spindle-celled types are more favorably influ¬ 
enced than are the osteosarcomata and chondrosarcomata, a fact easily un¬ 
derstood in view of the difference in the histological structure, the latter 
being composed largely of connective tissue. Sarcoma of the skin and 
lymphatic glands is usually amenable to irradiation. That of the long 
bones, even when recurrent after operation, will frequently “fade away” 
under this form of treatment. 

When the growth is in the mediastinum, marked relief of the symptoms 
and a temporary arrest of the condition, or even a regression in the size 
of the tumor, may often he obtained. 

As in carcinoma, it is advisable, if possible, to remove the growth 
surgically. Postoperative irradiation should always he employed. Pre¬ 
operative use of the X-ray is advocated, and when such a procedure is 
followed, if there is marked improvement in the clinical picture, and 
regression in the size of the tumor, it may he advisable to continue this 
form of treatment and postpone operative interference, the decision in 
this respect resting with the surgeon. At all times the closest coopera¬ 
tion between the surgeon and the radiotherapeutist is essential to the 
welfare of the patient. 

Technic .—This is practically the same as that employed in the treat¬ 
ment of the preceding condition. 

Uterine Fibroids. —Excepting the pedunculated type, and those in 
which the growth is at, or above, the level of the umbilicus, uterine fibroids 
can confidently he expected to disappear or markedly diminish in size 
under X-ray treatment. The reduction in the size of the tumor becomes 
noticeable after the second, sometimes after the first, treatment, and con¬ 
tinues, except for temporary enlargement during menstruation, until the 
mass can no longer be detected. 

The menorrhagia usually accompanying a fibroid is as a rule con¬ 
trolled after the first treatment, although in some cases the flow will show 
a temporary increase. Premature menopause is caused, which will he 
permanent if sufficient radiation has been administered, but menstrua¬ 
tion will he reestablished in from six months to two years if less than a 
sterilizing dose has been given. With the resumption of the menstrual 
epoch the fibroid may again enlarge. For this reason the patient should 
be kept under observation. 

Technic .—Using a 9-inch gap, 5 milliamperes, at 10-inch distance, 
and filtering through 3 millimeters of aluminum, 7 to 8 minutes’ exposure 


622 


X-RAY THERAPY 


is given to each of four areas anterior, two over the uterus, and one over 
each ovary, and on the second day following, to each of three corre¬ 
sponding areas posterior. Treatment is repeated every four weeks. 

With the 200,000-volt machine, a 35 per cent to 50 per cent erythema 
dose is given. Two portals, approximately 12 centimeters square (5 
inches), are utilized, one on each side of the median line anterior. 

Menorrhagia.—As in the above condition, the results of X-ray treat¬ 
ment are uniformly satisfactory. The same technic is employed, and, as 
a rule, three or four series are sufficient. 

The age of the patient is a very important consideration. If the time 
of the menopause is near, hastening it need cause no concern; but in 
younger women, particularly where there is a desire to bear children, it is 
advisable, if conditions permit, to give only sufficient radiation to stop 
the excessive flow without causing a disappearance of the menstrual epoch. 

No definite or fixed rule can be advanced as a guide for the num¬ 
ber of treatments necessary to accomplish this result. Generally, how¬ 
ever, after two successive menstruations have been missed, treatment may 
be discontinued, but the patient should be kept under observation for sev¬ 
eral months. Treatments may be resumed if indications warrant. 

Chronic Mastitis and Fibromata of Breast.—In chronic mastitis the 
pain and tenderness are quickly relieved, and the induration disappears. 
Fibromata gradually diminish in size, and after two to four treatments 
can no longer he detected. 

The breast may be divided into from two to four small areas, or the 
entire gland exposed through one portal, according to its size, and the 
extent of the involvement. Using a 9-inch gap, 5 milliamperes, 10-inch 
distance, 2 to 3 millimeters of aluminum filter, two-fifths to four-fifths of 
an erythema exposure is administered to each area every four weeks. 

Prostatic Hypertrophy.—The early relief from the frequency of 
urination, afforded by the use of X-ray, recommends its use, especially in 
those cases which are poor surgical risks. The residual urine is quickly 
eliminated, and the patient is enabled to sleep through the night without 
discomfort. The general health, which in these cases is so undermined 
by the lowered function of the kidneys, improves rapidly. When the 
enlargement of the prostate is the result of calcareous or fibrotic changes, 
no benefit will result from radiation, hut the adenomatous type will re¬ 
spond and uniformly good results will be obtained. 

Technic .—Three areas are irradiated, two of which are situated an¬ 
teriorly just above, and to either side of, the symphysis pubes; the third 
includes the entire perineum. Using a 9-inch spark gap, 5 milliamperes, 
10-inch distance, and a filter of 4 millimeters of aluminum, an exposure of 
four minutes is given every week as follows: The two anterior areas 
are irradiated at the first treatment; one week later the perineal area is 
exposed. It is advisable to protect the testes from the direct action of 


USE OF FILTERED RADIATION 


623 


the ray, although some operators advocate their exposure, claiming that 
more immediate results are obtained. Six to ten series are usually suf¬ 
ficient to overcome the condition. 

For exposing the perineal area the knee-chest position is assumed. 
Witherbee has constructed a special chair having the tube under the seat 
which greatly facilitates this treatment and is more comfortable for the 
patient. By his technic only the perineal area is exposed, treatments be¬ 
ing given each week. 

Tonsils. —Enlarged tonsils of the infected type are benefited by X-ray 
treatment, their size being reduced to normal, the hypertrophied lymphoid 
tissue being destroyed, and the pus evacuated from all the crypts. Cul¬ 
tures made from them after completion of the treatment are repeatedly 
sterile, and the systemic diseases produced by infection from the dis¬ 
eased tonsils are greatly improved, or cured. 

The effect of the ray is on the diseased lymphoid elements, which 
are destroyed and replaced by connective tissue. The contraction of the 
connective tissue fibers expresses the pus from the tonsil. This being 
the case, no benefit results when radiation is applied to tonsils already 
fibrotic. 

Usually six to eight treatments are given at biweekly intervals. The 
systemic condition, as well as the recurrent sore-throats of which these 
patients usually complain, shows improvement after the second or third 
treatment ; the reduction in size of the tonsils becomes apparent after the 
fourth to sixth treatment. The shrinking continues after treatment has 
been completed, and it is not until after six months that they reach their 
ultimate size. 

Occasionally it happens toward the end of, or even after, the series, 
that a white, glistening area will appear on the tonsil, having the appear¬ 
ance of an abscess or patch. This is due to the accumulation of pus in a 
buried crypt, which the contracting connective tissue is unable to express 
through the covering membrane. 

If left alone, such abscesses will eventually rupture, but it seems ad¬ 
visable to incise them in order to rid the economy more quickly of the 
infected material. 

The objections to this form of treatment for tonsils, as advanced by 
the profession at large, are many and various, but are not substantiated 
by facts. 

Danger to Thyroid, Submaxillary and Parotid Glands .—Sometimes a 
treatment will be followed within twenty-four hours by dryness of the 
throat and fauces, which persists from a few hours to a day. This con¬ 
dition is not permanent, and there has not been reported a single case, 
properly treated, that has suffered more than a very temporary diminu¬ 
tion in the action of the glands. 

If the thyroid and parotid glands are of normal size, they will not 


624 


X-RAY THERAPY 


project into the field of exposure, provided the shielding is properly placed. 

Danger to Pituitary Gland. —This gland is protected from the direct 
action of the ray by lead shielding around the area radiated, and conse¬ 
quently cannot be injured. 

Danger to Skin and Hair. —With proper shielding and technic, insuf¬ 
ficient radiation is applied to cause any damage to the integument or its 
appendages. 

Questionable Results. —It is time that some cases have not responded 
satisfactorily to irradiation, hut such failures are due either to faulty 
technic or to improper selection of cases. Nor are 100 per cent perfect 
results claimed by the advocates of this method, and there is no other 
form of tonsil therapy, not excepting surgery, where 100 per cent cures 
are obtained. 

Length of Time. —This is a valid objection to this form of treatment, 
and, in cases where immediate elimination of the affected focus is essential, 
other measures should be employed. 

On the other hand, the benefit from the treatment is seen relatively 
early, and in most cases the actual time lost is small. The advantages 
of this form of treatment may be briefly summed up as follows: 

1. Elimination of danger of death from anesthesia and postoperative 
hemorrhage. 

2. Avoidance of the possibility of lung abscess following tonsillec¬ 
tomy. 

3. In cases where surgery is contra-indicated, as in diabetic, hemo¬ 
philic, and cardiac conditions, this method offers a safe and almost cer¬ 
tain means of eliminating tonsillar focal infection. 

4. By this method of treatment not only the tonsils but the peri¬ 
tonsillar tissue and pharyngeal adenoids are benefited. 

Technic —Position.—The patient assumes the prone position, head 
turned to the side, resting on the ear, and slightly lowered to increase 
the distance of the angle of the jaw from the neck. The chin is tilted 
upward further to increase this distance. Thus we have a site bounded 
by the ramus of the jaw anteriorly, the anterior border of the sterno¬ 
cleidomastoid muscle posteriorly, and the level of the tip of the mastoid 
process superiorly, through which the ray will pass, not only to the tonsil, 
but to the peritonsillar tissue and the pharyngeal vault. 

Shielding.An opening 2% by 3% inches is made in a sheet of lead 
foil at least 3/16 inch thick. This is so placed that the tip of the mastoid 
process projects slightly into the opening at the center of the upper margin. 
The anterior border is slightly anterior to the posterior border of the ramus 
of the jaw. The head, face, and shoulders are covered with lead pro¬ 
tective. 


USE OF FILTERED RADIATION 


625 


Position of Tube.—The tube must be so placed that the central ray 
will strike the tonsil at right angles. This is most important. 

Exposure .—Using a 7-inch gap, 5 milliamperes, 10-inch distance, 
3 millimeters of aluminum, a three ond onedialf minute exposure is given 
to each tonsil every two weeks, for six or eight treatments. In cases where 
adenoids are especially to be affected, a third area at the occiput is radi¬ 
ated every other treatment. 

Cases are occasionally encountered in which irradiation every other 
week is impracticable. Under such circumstances, the above method must 
be altered, and using an 8-inch gap, 5 milliamperes, 10-inch distance, 
and a filter of 3 millimeters of aluminum, an exposure of five minutes to 
each tonsil is made every five weeks, for two or three treatments. This 
increased amount of exposure may be followed within twenty-four hours 
by an edema of the pharynx, which will be alarming to the patient, unless 
he has previously been advised of the possibility of such a reaction, and 
assured that it will be transitory, and not serious. 

Hyperthyroidism.— Toxic exophthalmic goiter is in most cases cured, 
or markedly benefited, by radiotherapy. The cystic and colloidal thyroid 
are not amenable to this form of therapy, since there is no glandular 
hypertrophy, and no toxicosis. 

In conjunction with X-ray treatment, frequent tests of the patient’s 
basal metabolism should be made, as it is the only absolute indication of 
the degree of toxicity, and consequently the only accurate guide for the 
frequency and number of treatments. When this test reaches + 10, or 
if the rate shows a rapid drop between tests, treatment should be dis¬ 
continued, but the patient should be kept under observation for a year 
or two, and radiation resumed if toxic symptoms reappear or the rate of 
basal metabolism shows an increase. 

The first improvement noted is a decrease in nervousness, reduction 
of pulse rate, and diminution of tremor. At about the same time, the 
patient begins to sleep better, and there is less sweating. The basal 
metabolism usually shows a slight decrease, but occasionally it will re¬ 
main at its high level for some time after the clinical picture indicates 
improvement. A gain in weight is usually noted early. 

The goiter is usually, but not always, reduced in size, sometimes dis¬ 
appearing altogether. The exophthalmus is the last and least affected 
symptom. Frequently there is no change, but as nutrition improves and 
emaciation disappears, the prominence of the eyeballs becomes less notice¬ 
able. 

If treatment is carried too far myxedema will result, and it is in 
order to avoid this unfortunate sequel that it is advisable to have a metab¬ 
olism test made before each treatment. Also by shielding the isthmus, 
and thus protecting it from the effects of the ray, the danger of hypo¬ 
thyroidism is greatly lessened. 


626 


X-EAY THEEAPY 


The thymus is very frequently involved in hyperthyroidism. Con¬ 
sequently it is customary with most operators to expose it at each treat¬ 
ment. In many cases, instead of exposing the thymus, an area on the 
back of the neck, extending from about the fourth cervical to the second 
dorsal vertebra may he irradiated. Eesults from this method have been 
equally satisfactory, the effect probably being due to the action of the 
ray on the sympathetic nervous system. Before X-ray treatment is in¬ 
stituted, it is advisable that a careful examination of the patient be made 
to eliminate the possibility of a focal infection or other underlying con¬ 
dition which may be the causative factor, for no benefit will result from 
irradiation until such source of infection has been removed. 

It is a common belief that following X-ray treatment of the thyroid 
there occurs extensive formation of connective tissue around the gland, 
which increases to a marked degree the difficulty of subsequent opera¬ 
tion, if such procedure is necessary. This contention is without sub¬ 
stantiation, by both experimental findings and the experience of the ma¬ 
jority of operators. 

In case of hyperthyroidism associated with menstrual disorders, no 
benefit may be obtained from irradiation of the gland. With such pa¬ 
tients, radiation applied to the ovaries will frequently correct both the 
menstrual and thyroid trouble. 

Technic .—Using an 8-inch gap, 5 milliamperes, 10-inch distance, and 
filtering through 3 millimeters of aluminum, 3 to 5 minutes’ exposure is 
given to each lobe of the thyroid, and to one area over the thymus (or 
back of neck) every two or three weeks for three or four treatments. If 
after the fourth treatment, there is no improvement, the case is regarded 
as unsuitable for this form of therapy; but if the clinical picture shows 
satisfactory progress, treatments are again resumed after two months, 
and a second series of three or four treatments is given. It has sometimes 
been found necessary to repeat these series several times, some cases 
having required as long as two and one-half years to cure, but usually a 
year or less is sufficient. 

When irradiating the ovaries, one-fifth of an erythema exposure should 
be administered to each ovary. 

In patients whose toxicosis is extreme, where collapse is imminent, 
X-ray is contra-indicated, its administration being sometimes followed by 
death. Such cases should be treated by other measures in an effort to 
improve the patient’s condition sufficiently to permit radiation. 

Hodgkin’s Disease.—Although X-ray therapy will not permanently 
cure Hodgkin’s disease, it will so ameliorate the symptoms, reduce the size 
of the glands, and improve the general condition, that months, or even 
years of comfortable and active life may be afforded the patient. In cases 
with the most unfavorable prognosis, patients have, as a result of treat¬ 
ment, been able to return to their usual occupations and the enjoyment 


627 


USE OF FILTERED RADIATION 

of reasonably good health. It has been observed by some authors that 
the cases responding most rapidly to X-ray therapy are more prone to 
early recurrence, and in these the prognosis is least favorable. 

The first evidence of improvement is a diminution in the size of the 
glands. This frequently occurs very soon after the first treatment has been 
administered. Cough, dyspnea, and other indications of mediastinal 
pressure, if present, are the next to be relieved. The discoloration of the 
skin is usually the last symptom to show improvement. 

Technic .—Some operators prefer to expose only the areas in which 
there is glandular enlargement, giving two-fifths to threerfifths of a filtered 
erythema exposure every four weeks. There are certain advantages in this 
method, particularly where it is necessary for patients to travel a consider¬ 
able distance for treatment, and the fatigue of travel makes frequent trips 
inadvisable. The best results have been obtained by dividing the trunk 
into twelve areas, three areas on each side of the chest and abdomen, and 
three on each side of the back, and exposing three areas every third or 
fourth day to one-fifth of an erythema exposure. By this method the 
anterior areas are exposed one week, and the posterior areas the next. In 
this way each area is exposed once every two weeks. It has not been found 
necessary to direct the ray toward the enlarged glands themselves, and 
it has been noted that those lying outside the areas radiated show the 
same diminution in size as do those within. 

Using a 9-inch gap, 5 milliamperes, 10-inch distance, with filter of 
3 millimeters of aluminum, two and one-half minutes’ exposure is given to 
each area. 

Treatment must be administered regularly, and continued except for 
an occasional rest, until the clinical picture is normal. Subsequently 
the patient must be kept under observation, and treatment resumed at 
the first evidence of recurrence of symptoms. With each recurrence the 
difficulty of controlling the disease may be increased, and the length of 
time between recurrences gradually diminishes, until the patient finally 
succumbs. 

Leukemia.—As in the preceding condition, the leukemias are chronic, 
recurrent diseases whose termination is always fatal, but the progress of 
the disease may be temporarily arrested, and from a few months to two 
years of comfort and activity added to the life of the patient by radio¬ 
therapy. One case has been reported in which the patient lived seven 
years. 

The white cell count is the guide for the amount of radiation and 
number of treatments, no radiation being given after the count reaches 
15,000. 

Technic .—The treatment is usually directed to the spleen and long 
bones, one-twelfth to one-eighth of an erythema exposure being given to 
each area every two weeks. The spleen is divided into twelve areas,, four 


628 


X-RAY THERAPY 


anterior, four lateral, and four posterior, four of which are exposed every 
other day during one week. The following week the extremities are ex¬ 
posed, as follows: On the first day one area on the anterior and one 
on the posterior surface of each arm, and of each forearm is exposed. On 
the third day three areas on the anterior surface of each leg and thigh, 
and on the fifth day corresponding areas on the posterior surface are 
irradiated. 

It has been observed that a continuance of treatment for a prolonged 
period sometimes results in the establishment of an apparent immunity 
of the patient to X-ray. In such cases, it has been noted that a com¬ 
plete change in the method of administration was immediately followed 
by improvement. One case of this kind was treated according to the 
above method for several months. The white blood count, originally 
236,000, was reduced to 40,000, hut could not be further lowered. By 
changing the technic and using that outlined for Hodgkin’s disease, ex¬ 
cepting that smaller amounts of radiation were administered, the count 
was quickly lowered to 10,000. 

Using 8-inch gap, 5 milliamperes, 10-inch distance, and 3 millimeters 
aluminum filter, from one to two minutes’ exposure is given to each area. 

Banti’s Disease. —In the limited number of cases of Banti’s disease 
which have been subjected to X-ray therapy, the reports indicate favor¬ 
able results, with reduction in the size of the spleen and improvement 
in the general condition of the patient. The spleen is never reduced to 
normal size, which is easily understood in view of the pathological changes 
in this condition, as the organ is already undergoing fibrous degenera¬ 
tion. The greatest reduction in size reported is about 50 per cent. This 
relief, of course, is only temporary, and cure cannot be expected. 

Technic .—Radiation is directed to the spleen, which is divided into 
small areas, so exposed that each will receive one-tenth of a filtered 
erythema exposure every week. 

Tuberculous Adenitis. —Disappearance, or marked diminution in size, 
and subsequent calcification of the glands, can confidently be expected in 
tubercular adenitis. However, treatments must be continued at regular 
intervals and for a sufficient length of time. Indeed, the only difficulty 
in the conduct of this condition is the length of time involved, which is 
discouraging to the patient and causes him to seek other measures of treat¬ 
ment producing more immediate results. 

The more recent the condition, the more rapid the response. The 
firmer the glands, the more readily they are influenced by the ray. Some 
cases require only four to five treatments, while others will require a 
year or more before all glands disappear or calcify. Glands which have 
broken down, or in which fluctuation is noted, should be incised and free 
drainage established before irradiation; otherwise the pus will eventually 
break through the skin, and more extensive scarring result. By using 


USE OF FILTERED RADIATION 


629 


picric acid or simple alcohol preparation, the aspiration of these glands 
may be accomplished without interference with X-ray therapy. The in¬ 
cision usually heals rapidly, but if difficulty of closure is experienced, 
a single exposure of the area to unfiltered radiation will in most cases 
hasten recovery. 

Improvement is first noted in the lessening of the pain in the glands, 
later in a reduction in their size. They become firmer, and eventually 
entirely disappear, or, when calcification takes place, only a small stone¬ 
like nodule remains. 

Technic. —Various operators use different thicknesses of filter, from 
1 to 5 millimeters of aluminum being advocated. No material advan¬ 
tage has been observed in any definite thickness of filter, but it has been 
the author’s custom to use 1 or 3 millimeters of aluminum, and, with 
an 8-inch gap, 5 milliamperes, at 10-inch distance, to give an exposure of 
from two to four minutes every three weeks. Better results have been 
obtained by dividing the neck into small areas, and exposing each area 
to this amount of radiation, than by exposing a single area including the 
one entire side of the neck. Exposing the opposite side of the neck for 
the benefit of cross-fire is advantageous. 

Using the 200,000-volt technic, a one-third erythema dose is admin¬ 
istered once every three weeks. 

Tuberculous Peritonitis. —The benefit obtained from X-ray therapy is 
remarkable in this condition, improvement being noted almost immedi¬ 
ately after treatment is begun. The abdomen is divided into four areas, 
corresponding to the quadrants, and each week one-fifth of a filtered 
erythema exposure is administered to each of two areas. 

Tuberculous Osteomyelitis. —X-ray treatment of this condition fre¬ 
quently proves beneficial. One-fifth of an erythema exposure every two or 
three weeks usually produces more satisfactory results than more in¬ 
tensive radiation less frequently administered. The discharging sinuses 
soon heal, and the progress of the disease is arrested, but regeneration of 
the bone is not to be expected. 

Pulmonary Tuberculosis. —Although a great deal of investigative 
work with X-ray has been conducted in an effort to combat this disease, the 
results have not been uniform, or, in many cases, even satisfactory. Some 
patients have benefited greatly by this form of therapy, which has many 
strong advocates. The consensus of opinion is that fractional exposures 
are superior to massive, two areas anterior and two areas posterior being 
exposed to one-tenth to one-fifth of a filtered erythema dose every other 
week. 

Sinusitis and Mastoiditis. —The use of X-ray in the treatment of acute 
and subacute sinusitis and mastoiditis is coming into greater prominence 
as the benefits derived from its administration are more widely appreci¬ 
ated. Cases characterized by pain over the affected cells and a constant 


030 


X-RAY THERAPY 


purulent or mucopurulent discharge are afforded almost immediate re¬ 
lief from the pain by one or two exposures. The discharge stops within a 
week. 

The closest cooperation between the rhinologist and the radiothera¬ 
peutist is absolutely essential. If necrosis of the hone, polypi, or fibrous 
changes are present, irradiation is contra-indicated. 

In treating the frontal sinus, ethmoid cells and antra, one area, which 
includes the entire region, is subjected to one-fifth of a filtered erythema 
exposure. This may be repeated at the end of two weeks. The eyes, 
eyebrows and hair should be protected by lead foil. 

The mastoid area is exposed to the same amount. 

Smaller amounts of radiation, given at shorter intervals, are advo¬ 
cated by some writers. 

Rose Cold and Hay Fever. —Frequently these conditions are greatly 
benefited by exposing the nose and accessory sinuses (as outlined in the 
preceding paragraph). 

Asthma. —When this condition is caused by enlarged bronchial glands, 
relief can be expected from the employment of X-ray therapy. 

The anterior and posterior surfaces of the chest are divided into six 
areas each, three on each side of the midline. One-tenth of a filtered 
erythema exposure is administered to each area every two weeks, six areas 
being radiated each week. Wilkinson reports particularly good results in 
this condition, but advises against exposing over the cardiac area. 

Pneumonia.— In unresolved pneumonia the X-ray has proven of great 
therapeutic advantage. One-fifth of an erythema exposure of filtered 
radiation is administered to each of four areas over the chest, two an¬ 
terior and two posterior, one area being irradiated every other day. A 
single series of treatments is usually sufficient. 

Sinus Tracts. —Postoperative sinuses or fistulous tracts, when not 
caused by irritating foreign bodies in the wound, can usually be healed by 
the administration of a few X-ray exposures. The entire area may be 
irradiated through a single portal, or the region divided into small areas 
around, and including, the wound. 

Using a 9-inch gap, 5 milliamperes, at 10-inch distance, filtered 
through 3 millimeters of aluminum, an exposure of three minutes is given 
to each portal every two or three weeks. Three or four exposures are 
usually sufficient. 

Neuritis. —Paroxysmal neuralgia and neuritis have been favorably 
influenced by the X-ray, especially those cases in which the paroxysms 
succeed each other at short intervals. Irradiation is applied over the area 
of emergence of the nerve roots, and, in some cases, along the nerve trunks. 

Long-standing, obstinate cases of sciatica are reported by Charlier 
as having been cured after ten exposures over the sacrum and lower lumbar 
region. 


SUMMARY 


631 


The amount of radiation administered varies according to the pref¬ 
erence of the operator, some advocating one-tenth of a filtered erythema 
dose every third day for five or six treatments, claiming that exposures 
of greater intensity may aggravate the pain. In the author’s experience, 
one-fifth of an erythema exposure given every week over the spine at the 
point of emergence of the affected nerves for three or four successive 
weeks has given very good results. It is sometimes of advantage to ir¬ 
radiate the entire affected area. 

Malaria.— The effect of irradiation on malaria is unique, and not 
clearly understood. The benefit that is derived may be due to the indirect 
action of the rays, through the effect on the white blood-cells, but seems 
more probably due to a direct action on the plasmodia. The disease 
follows a mild course, when recent cases are subjected to small exposures. 
Larger exposures cause a change in the cycle of the fever. Chronic cases 
which have proved obstinate under quinin administration make rapid 
recovery after irradiation, the organism disappearing from the blood 
within a week. 

A single series of exposures over the spleen is usually sufficient. The 
splenic region is divided into eight or twelve areas, and each area is sub¬ 
jected to an exposure of one filtered unit. Four areas are irradiated 
every second day. If necessary, a second series may be given at the end 
of two weeks. 

Pertussis. —While the work done has not been sufficient to establish 
thoroughly the status of X-ray as a cure for pertussis, still the experi¬ 
ments conducted by Bowditch and Leonard show results sufficiently satis¬ 
factory to warrant its use in this condition, and probably as favorable an 
outcome can be obtained by X-ray as by other methods of treatment. In 
some cases the spasms entirely cease after two or three exposures, while in 
others the spasms are greatly reduced both in number and severity. 

Technic .—The intensity of the exposure must vary with the age of the 
patient and the thickness of the filter employed, usually 1 or 2 millimeters 
of aluminum. The distance should be sufficient so that the area to be 
irradiated is entirely exposed (12 to 20 inches). Treatments should be 
given every three or four days, alternate exposures being made to the 
chest and back. The total amount of ray administered should be kept well 
under an erythema dose. 

Summary. —Owing to the limited amount of space, it has been impos¬ 
sible to present a minute study of the Roentgen ray and to describe in 
detail all the conditions amenable to X-ray therapy, together with the 
peculiar technic adapted to the treatment of each disease. The discussion 
must therefore be limited to a brief outline of the physics of X-ray, its 
general effect on the tissues of the human body, and its use in connection 
with the treatment of the more important and more common diseases 
which the radiotherapeutist is called upon to combat. As has been pointed 


632 


X-RAY THERAPY 


out, radiotherapy, from the standpoint of technic, divides itself into two 
branches, that is, superficial or unfiltered treatment, indicated in the 
majority of dermatological conditions, and deep or filtered therapy, in¬ 
dicated in conditions involving the deeper tissues. As stated, only the 
more important diseases have been discussed. There are many other 
conditions which respond favorably to the ray, such as verruca, callosity, 
syringoma, scrofuloderma, erythema induratum, furunculosis, etc. For a 
detailed study of the X-ray in connection with skin diseases, the author 
recommends the hook entitled X-ray and Radium Treatment of the Shin 
by Dr. George M. MacKee, which is doubtless the leading work on that 
subject. 

X-ray must not be regarded in the light of a panacea or cure-all. In 
many cases it does not cure at all, but merely inhibits the pathological 
cells, allowing the normal body forces to perform their normal functions, 
and sometimes merely affording relief. In some conditions X-ray alone 
will effect a cure. In others it is only a valuable adjunct to other forms 
of treatment. In many cases X-ray is tried as a last resort, when other 
measures have failed. Too quick and too brilliant results must there¬ 
fore not be expected, but time must be allowed, and this form of treat¬ 
ment regarded with the same tolerance as other forms of therapy. It 
must also be remembered that in certain diseases no hard and fast rules 
for treatment can be laid down, but each case must be treated as an in¬ 
dividual one. In such instances it is impossible to give a satisfactory 
prognosis. 

Generally speaking, the X-ray has an unlimited field of usefulness 
in medicine and is one of the most valuable therapeutic agents which mod¬ 
ern science has to offer. Its success, however, depends upon careful diag¬ 
nosis, the proper selection of cases, a thorough and well-mastered technic, 
and a close cooperation between the physician or surgeon and the radio¬ 
therapeutist. Finally, while at the present time X-ray therapy has its 
limitations and must not be regarded as a panacea, yet its scope of use¬ 
fulness is constantly increasing, and, with a better understanding of its 
value and a closer professional cooperation, it presents unlimited pos¬ 
sibilities for the future. 


CHAPTER XV 
ORGANOTHERAPEUTICS 
A. J. Carlson 

INTRODUCTION 

Definition.—The term “organotherapy” may be defined as the success¬ 
ful control of the disease syndrome due to the hypofunction of an organ, 
by administration of the organ itself or of substances prepared from this 
organ . Other terms, sometimes employed synonymously with organo¬ 
therapy, are opotherapy, zootherapy, histotherapy, sequardotherapy, 
hormone therapy, etc. 

The above definition strictly excludes organ transplantation as a part 
of organotherapy. It also excludes the principles and methods of using 
substances derived from animal organs for specific actions not primarily 
related to the function of that organ in life; for example, the use of 
pituitrin or extracts of the posterior lobe of the hypophysis to control 
the uterine contractions in labor ; the use of thyroid substance to control 
obesity; the use of adrenalin to control local hemorrhage, or retard local 
absorption. 

Organ Transplantation.—There is a much wider range of possibilities 
in organ transplantation than in organotherapy. When physiology and 
surgery shall have advanced to a point where an organ like the kidney 
can be transplanted as a permanent substitute for a diseased kidney, no 
one doubts that the symptoms of nephritis due to the diseased kidney will 
be permanently controlled. But no amount of advance of chemistry and 
biology will ever enable us to cure uremia due to kidney disease by the 
administration of kidney extracts. 

It is, or ought to be, evident, that organs like the liver, the lungs, 
and the kidney, which through the action of their living cells remove toxic 
substances from the blood, control the chemical equilibrium and the metab¬ 
olism of the body, not through substances stored up in the cells and given 
off to the body fluids, but through processes dependent upon their living 
structure. The control of deficiency of this type of organs by administra¬ 
tion of organ debris or organ products is as futile as the attempt to re- 

633 



634 


ORGANOTHERAPEUTICS 


pair the effects of a broken wheel in the machinery of a watch by pour¬ 
ing into the watch-case a powdered watch wheel. A whole wheel and 
nothing else will start the watch machinery going. But in actual prac¬ 
tice, at present, there is not a sharp distinction between organotherapy 
and organ transplantation, at least as regards some of the endocrine 
glands. It is a fact that transplantation of a thyroid or an ovary from 
one person to another has so far been only a temporary success. The 
transplanted organ undergoes atrophy or lysis and absorption, sooner or 
later; that is, heterotransplantation of any of the glands of internal se¬ 
cretion amounts to little more than the subcutaneous or intramuscular 
administration of the extracts of these organs. The surgery of hetero- 
transplantation of an endocrine gland is simple, the reasons for only a 
limited life of the graft are partly known, but there is little hope that 
the modification of individuality within the species necessary to render the 
transplant permanent will be an accomplishment of to-morrow. 

The continued study of the chemistry and biological reactions of ex¬ 
tracts of animal organs will gradually reveal substances having specific 
and useful drug actions not related to the living role of the organ in the 
intact animal. At present we have two such substances in epinephrin 
and pituitrin. When epinephrin is used in medicine as a local styptic 
or in bronchial asthma, and pituitrin to induce uterine contractions, these 
are as distinctly drug actions as the use of digitalis to stimulate the heart 
or atropin to dry up the secretions. No one supposes that the physi¬ 
ological actions of the latter alkaloids in the animal body bear any re¬ 
lation to the role of these alkaloids in the plants which produce them. 
The hypophysis antedates the uterus in animal evolution by myriads of 
ages, and, so far as we know, the mammalian male has the same kind of 
hypophysis as the female. If the term organotherapy is to include these 
distinctly drug actions and uses of animal substances, it seems we ought 
to speak of the useful actions of vegetable alkaloids as plant organotherapy. 

On the other hand, it is being recognized that some of the effects of 
well-known drugs may be due to specific actions upon organs of internal 
secretion. Some of the effects of iodin, for example, may be due to the 
fact that it increases the amount or potency of the internal secretion of 
the thyroid. There is evidence that certain foods also increase the activity 
of some organs of internal secretion. 

The definition includes the successful use of digestive enzymes in the 
control of the disorders of digestion following hypofunction of the diges¬ 
tive glands. But as commonly understood, organotherapy is limited to 
the use of specific substances or hormones from the organs of internal 
secretion . 

History. —Empirical organotherapy, or the attempt to control symp¬ 
toms of organ disease by feeding the patient the healthy organs of animals, 
is one of the oldest forms of therapeutics. 


INTRODUCTION 


635 


The use of animal extracts in medicine is referred to in the Papyrus 
Ebers, one of the oldest manuscripts in the history of medicine. Organs 
or organ extracts of animals had a place in the medical superstitions of 
the ancient Hindus and in the therapy of Hippocrates, Dioscorides, and 
Galen. The naive empiricism of the organotherapy of the early Greek 
physicians was not improved upon by the physicians of the Middle Ages. 
We find that the liver of the pigeon and the wolf was recommended for 
hepatic disorders, powdered human heart and the brain of the rabbit for 
epilepsy, extract of human brain for “debility,” the lung of the fox for 
dyspnea, rennet for gastric disorders, the testicles of the donkey and the 
stag for depressed sex functions, etc. 

It would seem that the use of extracts of lung, liver, kidney, etc., to 
cure hypofunctioning of these organs presupposes complete ignorance of 
the physiology of these organs. How much urine will be excreted by a 
dried and powdered kidney, or how is it possible for a lung extract to 
send oxygen into and to take carbon dioxid out of the blood ? But liver, 
kidney, brain, etc., in powder form, tablets, or solution, are on the market 
to-day as therapeutic remedies. Studying the lists of organotherapeutic 
preparations on the market to-day, all claiming support from clinical 
results, one gains the impression that some of our drug manufacturers are 
guided by the medical superstitions of the Orient, and by medieval medical 
lore rather than by the modern sciences of physiology, pharmacology and 
pathology. 

The hundreds of glandular products listed in trade journals include 
brain, spinal cord, liver, lung, bronchial gland, lymph glands, spleen, 
carotid gland, muscle, leukocytes, blood, hone marrow, etc. They do 
not differ greatly from the lists of a century or two ago; the chief dif¬ 
ference is that the “indications’’ are expressed in more modem but none 
the less obscure phraseology. The therapeutic use of many of these organ 
preparations by the physicians of to-day is a discouraging instance of 
therapeutic atavism. 

The older organotherapy was based on the belief that it was possible 
to influence a diseased organ by the administration of the same but healthy 
organ from animals; modern organotherapeutics is concerned, primarily, 
not with the condition of the organ diseased, hut with the activities of 
other organs which are impaired by the absence or diminution of an in¬ 
ternal secretion of the diseased organ. Thus, thyroid is not given pri¬ 
marily for its effect upon the thyroid gland, but for its effect upon various 
other organs whose activities are in part dependent upon the internal 
secretion of the thyroid. 

Recent experimental and clinical work in this field has accordingly 
been directed to two chief aims: (1) the demonstration that various organs 
produce internal secretions; and (2) attempts to determine the conditions 
under which these may be utilized for therapeutic purposes. 


636 


ORGANOTHERAPEUTICS 


Great progress has been made in the former attempt; it has been shown 
that many organs produce internal secretions essential to life, or essential 
to normal life. Much less progress has been made in the successful utiliza¬ 
tion of these internal secretions in disease, and we are only beginning to 
he able to explain the cause of some of the failures. 

The first step in rational organotherapy was taken by Brown-Sequard, 
in 1889, in his work on the physiological effects of extracts of the testicles. 
The work of this French physiologist was not well controlled, and his 
claims greatly exaggerated. Nevertheless, his theory that “all glands, 
whether they have excretory ducts or not, secrete useful principles, the 
absence of which is felt when these glands are extirpated, or destroyed 
by disease/’ foreshadowed the modem “hormone” physiology. Rational 
organotherapy was finally established in the early nineties by the suc¬ 
cessful control of the symptoms of thyroid hypofunctioning by the use of 
thyroid extract, through the work of Schiff, Reverdin, Kocher, Eox, 
Mackenzie, Murray, and others. This brilliant achievement has had two 
effects on subsequent biological investigation and clinical practice: (1) it 
has been a potent stimulus in establishing similar types of function and 
methods of practical control for other organs of the body; (2) it has 
stimulated the clinical use of other organ preparations without definite 
physiological indications of their value and without experimental control. 


GENERAL PRINCIPLES OF ORGANOTHERAPY 

Hormone Substance Essential.—Successful treatment of the symp¬ 
toms of hypofunction of an organ by extracts of said organ requires that 
the essential function of the organ consists in producing a substance or 
substances in the nature of hormones. 

It follows as a necessary corollary to this principle that organotherapy 
is out of the question in the case of tissues in which the production and 
storage of such substances are either absent or of no fundamental impor¬ 
tance in the function of the organ. The lung tissue permits or produces 
the exchange of oxygen and carbon dioxid between the blood and the air. 
So far as we know the lung tissue does not store any substance that can 
in any way facilitate lung function or act as a substitute for the living 
lung. Hence, the certain futility of lung extract therapy of pneumonia 
or pulmonary tuberculosis. 

The same general situation exists in regard to the kidneys, the liver, 
the nervous tissue, the heart and muscular tissue in general, and possibly 
other organs. No amount of flooding of the body fluid with kidney ex¬ 
tracts can separate the urinary constituents from the blood in the ab¬ 
sence of living kidney cells. The liver plays a complex part in the body, 
and part of its function may he the production of important hormones; 


GENERAL PRINCIPLES OF ORGANOTHERAPY 637 

but other important liver functions, such as glycogen storage, protein 
deamidization, synthesis of urea from ammonia, desaturation of fats, 
bile formation, etc., cannot be carried out by liver extracts. The futility 
of brain extract therapy in the case of defects or destructive lesions of 
the nervous tissue is equally apparent. 

The only possibility for organotherapy in the case of the tissues just 
referred to is the chance or evidence that these tissues contain substances 
capable of stimulating the impaired organ or organs to increased activity. 
Eor example, the kidney may contain a substance that stimulates the 
living kidney cells to increased secretory activity, although the substance 
itself cannot secrete urine. It is supposed, for example, that the mam- 
mary glands contain galactagogue substances. Substances may be prepared 
from the gastric mucosa that induce secretion of gastric juice when in¬ 
jected into the blood. The liver contains a cholagogue in so far as it 
contains bile elements. Nervous tissue is rich in lecithin, and some have 
held that administration of lecithin is favorable for the growth and 
metabolism of nervous tissue, etc. 

The existence of such specific organotropic substances in these various 
organs must first be demonstrated by accurate laboratory experiments be¬ 
fore one is justified in using such organ extracts on patients, where even 
under the best of conditions all the factors cannot be controlled. The 
indiscriminate use of tissue extracts in maladies of unknown or complex 
origin leads to confusion. At least one can place little credence on the 
results of such clinical use of organ extracts until supported by laboratory 
experiments on animals. This principle must be insisted on all the more 
since many of the clinical lesions of the kidneys, lungs, liver and brain 
can be reproduced experimentally in animals. 

A typical case in point is the testicular “spermin” of Poehl, which 
was proclaimed as a general metabolic stimulant, and for a time used as 
a “cure-all” by a few uncritical enthusiasts. 

Primary Hyperfunction Not Altered by Organotherapy.—There is 
little or no hope for successful organotherapy in diseases due or supposed 
to be due to a primary hyperfunction of organs. Where a malady is def¬ 
initely traced to primary hyperfunction of an organ, the remedy is sur¬ 
gical (direct or indirect), not medical. But the question of an out-and- 
out organ hyperfunction, including serious clinical disorders, is at present 
a complex and uncertain chapter in medicine. Gastric hypersecretion 
or hyperacidity is supposed to cause certain symptoms in gastric and duo¬ 
denal ulcers, and in so-called vagotonia. The syndromes of toxic goiter, 
acromegaly, hemolytic jaundice, and certain types of anemia, hyper- 
genitalism, and osteomalacia are held by many scientists and clinicians 
to be caused by hyperactivity of the thyroid, hypophysis, spleen, pineal 
body, adrenal cortex, and gonads, respectively. If it shall be clearly estab¬ 
lished that sufficient hyperactivity of these and other glands of internal 


638 


ORGANOTHERAPEUTICS 


secretion cause disease, the only type of organotherapy that may he of 
value is the administration of organ extracts that depress the hyperactive 
gland—if there are such extracts. For example, it has been reported that 
administration of ovarian extract to young male animals retards the de¬ 
velopment of the testes, and the observations of Lillie on the Freemartin 
seem to show that the testicular and ovarian secretions have some mutual 
inhibitory action on the development of the respective sex characters, at 
least in early embryonic life. This type of organotherapy is at present 
purely empirical, and should be well grounded by animal experiments 
before it is applied to patients. If the hyperactivity of a gland is a 
compensatory one, administration of extract of that gland may arrest the 
gland growth but will not control any other symptoms. The “hyperplasia” 
that may be induced in some endocrine glands by extirpation of other 
endocrine glands is no evidence that the extirpated glands secrete hormones 
holding the other glands in check. Hence, there is at present no experi¬ 
mental basis for a pituitary organotherapy of toxic goiter. If the glandu¬ 
lar hyperplasia and hyperactivity is primary, such organotherapy is clearly 
contra-indicated. 

Dystrophy and Perverted Secretion.—There are at present no definite 
indications for organotherapy in disease due or rather supposed to be due 
to organ dystrophy, that is, a perverted or pathogenic secretion. 

The theory of a perverted or pathogenic secretion as the cause of dis¬ 
ease has been advanced for some of the maladies related to the glands of 
internal secretion, notably the thyroid and hypophysis. The theory has 
little or no basis in established fact. But assuming it is true, the fol¬ 
lowing possibilities must be considered: (1) The gland may yield both 
the normal and the pathogenic secretion. In that case the patient will 
show no symptoms of glandular hypo-activity, the symptoms of the dis¬ 
ease being solely due to the perverted secretion. In such a case specific 
organotherapy will in all probability prove useless, as there is no reason 
for believing that the normal secretion of the gland will control the patho¬ 
logical secretion. (2) In yielding the pathological secretion the gland 
may be so altered that the normal secretion is diminished or absent. This 
is the most likely condition. In such a case the syndrome will be a com¬ 
plex of glandular hypo-activity and pathogenic secretion, and it is obvious 
that organotherapy may have a favorable effect on the hypoglandular 
symptoms but leave the pathogenic secretion symptoms unaffected. 

Accumulation of Hormones.—The hormone or hormones must be 
stored up in active form, and in some quantity in the organ producing 
them, for successful organotherapy of this organ. 

It is obvious that unless the specific hormone in question is stored in 
the gland to some extent, administration of the gland extract in hypofunc- 
tion of the gland will be useless. For example, a glycerin extract of 
gastric mucosa contains pepsin, but no hydrochloric acid, although both 


GENERAL PRINCIPLES OE ORGANOTHERAPY 639 


of these substances are produced by the gland cells and are of equal im¬ 
portance in gastric function. The reason is evident. Pepsin is stored 
up as pepsinogen in the resting cells while the hydrochloric acid is not 
stored up but discharged from the cell as soon as formed. Hence, a gastric 
mucosa extract contains the former hut not the latter, and in organotherapy 
of the gastric mucosa hydrochloric acid must be added from some other 
source. Analogous conditions may obtain in some of the endocrine glands. 
It is, therefore', important in determining to what extent the internal se¬ 
cretions are stored in the organs producing them, and how much of them 
is necessary to maintain health. This is possible, in a general way, in the 
case of a few organs. Thus, from studies on the amount of thyroid 
which it is necessary to administer to maintain health in animals or man 
suffering from removal or disease of the thyroid, it is possible to form an 
approximate estimate of how much thyroid secretion is necessary, and from 
the weight of the gland how much material is stored in it. Such calcula¬ 
tions show that the normal thyroid contains sufficient secretion to meet 
the demands of the body for several weeks. 

From a determination of the amount of epinephrin contained in the 
blood of the suprarenal vein, and from the rate of blood flow through the 
suprarenal glands, it is possible to make a rough estimate of the amount 
of epinephrin produced daily. When the amount is compared with that 
actually found on chemical analysis in the suprarenal glands, it is found 
that the latter is equal to the epinephrin output for only a few hours. 
Since some of the internal secretion is almost invariably lost or destroyed 
in the manipulations necessary to prepare the gland for administration, 
it is evident that the conditions in the case of the thyroid are far more 
favorable for success than in the case of the suprarenals and the pancreas. 

In addition to knowing how much of the secretion is stored in the 
gland, it is important to know how urgent is the body’s need for the secre¬ 
tion, and how long the latter remains in the body. Light on these ques¬ 
tions has been obtained by determining how soon symptoms appear after 
removal of the glands. Taking two extremes, it has been found that 
symptoms may not appear for weeks or months after removal of the 
thyroid, whereas they appear within four to eight hours after removal 
of the pancreas, and they may appear within a few hours after removal 
of the parathyroids, or the adrenal cortex. It is evident that the chances 
for successful organotherapy are much more favorable in the case of the 
thyroid gland. 

Stability of Hormone.—The physiologically important hormone stored 
in the gland must be sufficiently stable to resist the necessary chemical 
processes of making the gland extract; and, for practical organotherapy, 
the hormone must resist the action of the digestive enzymes and must be 
absorbed into the blood in active form. 

This is probably the most serious limitation of organotherapy. All 


640 


ORGAHOTHERAPEUTICS 


hormones are probably (in fact, must be) soluble in serum or Ringer’s 
solution. But, because of the necessity of continuous or daily admin¬ 
istration, intravenous or hypodermic injections of extracts of the entire 
glands produce toxic effects, in some cases more serious than the symptoms 
treated, owing to the presence of injurious tissue split products. The 
chemical manipulation necessary to remove these toxic by-products in¬ 
troduces greater chances for destruction or loss of the hormones them¬ 
selves. Moreover, intravenous or hypodermic injections must as a rule 
be done by a physician or a nurse, and even when this is done there are 
chances for local and general infections when employed daily or several 
times a day for months and years. This is one of the difficulties of the 
“insulin” therapy of diabetes. Practical organotherapy thus limits itself 
in most cases to administration of the gland or the gland extract by mouth. 
That is, the hormone must run the gamut of enzyme action both in the 
lumen of the alimentary tract and in the wall of the absorbing intestine. 
In view of this fact, the failures of organotherapy, are less surprising to 
biologists than the striking success in the case of the thyroid. If the 
founders of thyroid organotherapy had known of the general completeness 
of the protein and fat hydrolysis in the digestive tract, we believe they 
would scarcely have had courage to try the feeding of thyroid in myxedema 
and cretinism. 

Classical examples of destructive action of the digestive enzymes on 
hormones and alleged hormones, or failure of these hormones to reach the 
blood in active form when administered by mouth, are: epinephrin , pitu- 
itrin, “insulin ” and the pancreatic and gastric secretins . 

Activity of Hormone.—The hormone must be present in the gland in 
active form; be activated by the chemical processes of preparing the ex¬ 
tract, or the normal activator added to the gland or the extract. 

The thyroid hormone, as well as epinephrin, pituitrin, “insulin,” 
are present in the glands in active forms or activated by the processes 
of extraction. Whether any of the other internal secretions are stored 
as pro-hormones and must be activated in or by the products of other 
organs has not yet been determined. Miinser assumes that all the endo¬ 
crine glands work in pairs, one activating or inhibiting the other. He 
therefore concludes that before an organ is used in organotherapy it must 
be “activated” by previously removing the inhibiting gland from the 
animal. For example, before using the pancreas of an animal to con¬ 
trol pancreatic diabetes in a patient, the animal must have had the an¬ 
terior lobe of the hypophysis extirpated some time before the pancreas 
is excised in order to yield an “activated” pancreas. This fanciful theory 
is not borne out by the well-established facts of thyroid organotherapy, 
and we shall point out later that extirpation of some of the alleged in¬ 
hibitors of the adrenals do not influence the epinephrin content of the 
gland. 


GENERAL PRINCIPLES OF ORGANOTHERAPY 641 

Hedon claims that, when the blood from the pancreatic vein is in¬ 
troduced into the portal circulation of a diabetic animal, there is a 
diminution of the glycosuria, while it has no effect when introduced into 
the general circulation. Thus he concludes that it is necessary for the 
internal secretion of the pancreas to reach the liver in order that it 
may be active. But Hedon’s results are disputed by Carlson. In any 
event, it is a fact that the establishment of an Eck fistula in animals 
does not induce hyperglycemia and glycosuria on ordinary carbohydrate 
rations, despite the fact that by this operation all the portal blood, in¬ 
cluding that from the pancreas, is sent into the general circulation before 
a small fraction of it reaches the liver by way of the hepatic artery. 
Hedon’s theory is untenable in view of this fact. But we have a. classical 
example of such “distant activation” in trypsinogen and enterokinase; 
and the possibility of analogous conditions in the gland of internal secre¬ 
tion, where all attempts to isolate or demonstrate active hormones have 
so far been failures, must always he kept in mind and tested. 

Standardization of Products.—The hormones must he relatively 
stable in the form in which the gland or gland extract is put on the mar¬ 
ket for therapeutic or research purposes; and the organ preparations must, 
so far as possible, be chemically and physiologically standardized. 

No argument is needed in defense of this principle, although it is not 
always complied with. Stability of the hormones may not be attainable, 
in which case we must have recourse to fresh glands or fresh extracts. The 
only criticism that may be legitimately directed against manufacturing 
concerns in such cases is for failure to indicate the date of preparation 
of and the rate of deterioration of the extract. While pancreatic secretin 
has so far proved to be of no therapeutic value, it can be prepared in 
active form, but not kept from rapid deterioration, so that* the prepara¬ 
tions on the market become inert in a few weeks. This would be serious 
in case the active secretin was of any value in curing or controlling disease. 

The chemical and physiological standardization of such substances as 
thyroid, pituitary and adrenal extracts or “insulin” is just as important 
as the standardization of diphtheria antitoxin. It should be insisted on 
by the profession, and required by law, in view of the fact that the prepara¬ 
tions on the market may show great variations in physiological activity. 
This is obviously a great drawback to the successful use of these substances 
in disease. The standardization of “insulin” is imperative in view of 
the serious consequences of an overdose of this substance. 

The importance of chemical and physiological standardization of prep¬ 
arations of the parathyroid and the corpus luteum is equally obvious. 
The parathyroids are very small organs, distributed on and in the thyroids, 
and, in some cases, in the thymus. It takes a good deal of training and 
care to avoid the inclusion of small accessory thyroids, or nodules of 
thymus in gathering fresh parathyroid material. There is some evidence 


642 


ORGANOTHERAPEUTICS 


of variation in function of corpus luteum with the age of this temporary 
organ, and with the incidence of pregnancy. Even the most careful manu¬ 
facturer, therefore, is facing great difficulties, since his only sources of 
material are the abattoirs and the only criterion of the time of ovulation 
in the abattoir animals is the appearance of the ovary by direct inspec¬ 
tion. Dannereuther states that only one of the several drug firms who 
place ovarian products on the market would affirm that their corpus luteum 
preparations are made from the corpus luteum of pregnant animals. 
There exists, at present, another serious source of error or cause of dis¬ 
crepancies in therapeutic effects in the usual practice of removing fats or 
lipoids from the dried products or solutions of such organs as the ovary, 
the hypophysis, and the adrenal cortex. The solvents that remove the 
lipoids may also remove the hormones. Until the hormones have been 
actually isolated it would seem more promising to use the entire gland, 
at least when given by mouth. 

Clinical Control in Use of Organ Extracts. —In case of the endocrine 

glands, in which organotherapy is still in the balance, the clinical use of 
organ extracts should he most rigidly controlled and should he preceded 
or paralleled by animal experiments. 

Empirical organotherapy is not to he condemned entirely, but when 
organ extracts are used in this way without the guidance or positive in¬ 
dications from physiology or pathology, medical progress demands that 
other factors he eliminated so far as possible, so that the results may 
have some meaning. A careful perusal of the literature will convince 
any candid man that we are great sinners in this regard. The other fac¬ 
tors we refer to are: (1) other therapeutic measures such as changes in 
diet, occupation, environment, etc., simultaneously instituted; (2) the 
element of suggestion; and (3) the natural history of the malady. For 
example, if we disregarded the natural course of colds, or mumps, or chorea, 
we could readily establish a splendid organotherapy of these diseases. 
This is too obvious to mention, except for the fact that our literature 
demonstrates that it is so frequently forgotten. Our age has been char¬ 
acterized, medically, as one of therapeutic nihilism. On the contrary, 
in the field of internal glandular diseases and organotherapy , it is an age 
of therapeutic credulity and foolish faith in the biological and medical 
omniscience of drug manufacturers. 

The ideal scientific control is not easily attained in most clinical cases. 
There are the spontaneous fluctuations in the severity of symptoms, spon¬ 
taneous repair, irrespective of all therapy, and factors of general hygiene 
and nutrition which the good physician always endeavors to improve. 
There are the uncertainties of diagnosis in all border-line cases, especially 
in the so-called pluriglandular diseases. Hence, the value of the guide and 
aid of definitely controlled animal experiments. Clinical results will ever 
constitute the final test of organotherapy in any given condition, but in- 


GENERAL PRINCIPLES OF ORGANOTHERAPY 643 


telligent cooperation of the clinic and the laboratory will assure a quicker 
arrival at the truth. 

The Dangers in Organotherapy.—When, as in the case of the thyroid, 
oral administration is effective, this method should he used exclusively as 
a routine procedure. There is danger in overdosing with thyroid extract, 
even when given by mouth, but all of the other endocrine preparations 
can be administered per os in large doses, and for long periods with little 
or no deleterious effects. There may also be no evidence of beneficial 
effects, but that is another story. We are now concerned with the dangers 
of organotherapy. 

Intravenous organotherapy is the most dangerous; hypodermic and 
intramuscular administration is less dangerous than the intravenous route, 
hut hypodermic injections of crude organ extracts are capable of seriously 
injuring the patients through (1) anaphylaxis; (2) toxic protein deriva¬ 
tives (histamin, peptones, etc.) ; (3) toxic lipoids (cholin, neurin, etc.) ; 
(4) local damage of tissues at the site of injection. Hence, as a general 
principle, organ extracts of unknown composition (and this includes all 
of them except thyroxin, adrenalin, and with some reservations, pituitrin 
and “insulin”) must not he given intravenously or hypodermically, es¬ 
pecially when repeated administrations are called for. Crude endocrine 
products parenterally administered introduce the additional danger of 
non-specific protein therapy. We must clearly recognize that intravenous 
or hypodermic therapy is always unphysiological, and should be used 
only with pure products, and when the oral route yields no results, or too 
slow effects. 

The principle laid down in this paragraph puts a serious task before 
the manufacturer of organotherapeutic products, a task demanding the 
highest grade of scientific ability, and complete integrity; in fact, a higher 
type of accuracy and integrity than that required in ordinary honest 
business. 

Early versus Late Therapy in Endocrine Hypofunctions.—The im¬ 
portance of early diagnosis and therapy of hypofunctions of the glands of 
internal secretion is obvious, since the early therapy may check further 
deterioration in the gland system primarily involved, and prevent the 
development of non-reversible atrophies or abnormalities in other organs. 
Early therapy may thus be effective, while late treatment is less or even 
non-effective. But sex aplasia and absence of adolescence due to hypo¬ 
thyroidism may, in some cases at least, be corrected by thyroid organo¬ 
therapy begun as late as the thirtieth or fortieth year. 

While we all subscribe to this principle, the great difficulty comes in 
the application, from the fact that none of the incipient symptoms of hypo- 
function of any endocrine system are specific. For example, the primary 
etiology of slight nervous disturbances, slight adiposity, slight disturb¬ 
ance in growth, slight disturbances in sex functions, slight disturbances 


644 


ORGANO THERAPEUTICS 


in metabolism, slight mental retardation or inferiority, etc., may lie en¬ 
tirely outside the endocrine field, and it is now claimed by some that 
both hyperthyroidism and hypothyroidism may be present in persons who 
have a normal basal metabolic rate. Early diagnosis becomes, therefore, 
essentially guesswork, and the meaning of positive results of organo¬ 
therapy based on a guessed diagnosis become also a matter of guess. This 
is undoubtedly one of the most disturbing factors in evaluating the re¬ 
sults of organotherapy at present. How are we to proceed with fairness 
in face of the following facts ? 

1. Hone of the incipient symptoms of endocrine hypofunction are 
specific. 

2. Slight hypofunction of any one of the endocrine glands may be 
only temporary, with spontaneous recovery. Any therapy of such con¬ 
ditions is apt to lead us to wrong conclusions, and thus impede the progress 
of medical art and science. 

3. Prolonged and marked hypofunction of at least some of the glands 
of internal secretion (for example, the thyroids, parathyroids, pancreas) 
may induce a more or less irreversible pathology in other organs, render¬ 
ing late therapy less effective. 

What is the doctor to do in this dilemma ? Is he to apply an in¬ 
discriminate or pluriglandular therapy in incipient and uncertain cases, 
on the chance of a random hit, or is he to await developments, thereby 
possibly harming the patient ? 

It would be presumptuous for any one man to dictate the line of con¬ 
duct here, but I think the following points are within reason: 

1. When the diagnosis is a guess, let us all admit that the meaning 
of therapeutic results is also a guess. 

2. Internists as well as laboratory men should make greater efforts 
to work out reliable criteria of incipient endocrine hypofunctions, and 
determine more clearly the time factor of the irreversibility of endo- 
crinopathic sequelae. 

Uniglandular versus Pluriglandular Organotherapy. —In recent years 
there has been a tendency to abandon the use of single gland products in 
favor of gland mixtures. This tendency has been particularly marked in 
the case of the thyroid, the hypophysis, the gonads, and the adrenal cortex. 
We do not include here the extreme tendency in this direction—the in¬ 
clusion in organotherapeutic mixtures of extracts of organs (like the 
kidney, the lymph gland, the spleen, the brain, etc.)—where evidence of 
endocrine function is entirely lacking, and the use of these mixtures as 
general or “supportive” therapy for all kinds of disorders. This is quack 


GENERAL PRINCIPLES OF ORGANOTHERAPY 645 

practice rather than medical practice. The combined administration of 
extracts of organs of known or probable endocrine functions as empirical 
therapy is based on the following considerations: 

1. There is some evidence of mutual interdependence of some of the 
endocrine glands. Thus the normal functioning of the gonads depends, 
among other things, on the thyroids, and possibly the hypophysis, and the 
adrenal cortex, while extirpation of the gonads leads in some species to 
changes in the hypophysis, thymus, and the adrenals. 

2. Endocrine glands, like the thyroids or the pancreas that have 
fundamental influences on the general metabolism and growth, will neces¬ 
sarily influence the other glands as well. Apart from this type of facts, 
the theories of specific influence (stimulation or inhibition) of one gland 
on others rest on precarious foundations. But it is quite probable that 
conditions like dietary deficiencies and chronic or acute infections have 
some effects on the entire endocrine system, and more so on some than on 
others. 

3. The above consideration has led to the theory that endocrine dis¬ 
orders are seldom if ever confined to single systems, that they are, in 
fact, pluriglandular. The corollary to this theory is the pluriglandular 
therapy of these diseases. But it must not be forgotten that, in the experi¬ 
mental animal, specific diseases are produced by damaging specific glands 
of internal secretion and, so far as organotherapy is at all effective, it 
suffices to administer the product of the damaged gland to control the 
disease. It is not necessary, for example, to add pituitary, gonad, or 
adrenal cortex to the thyroid extract to control experimental cretinism 
or myxedema. 

4. Fortunately, to date most pluriglandular therapies have been ad¬ 
ministration of the mixtures by mouth. In this way the least damage 
is done to the patient. But the specious theory that we can supply the 
human body with any quantity and quality of endocrine pabulum, the 
internal coordination being so perfect that the body cells pick out only 
the kind and quantity of hormones needed, is not only without basis in 
demonstrated facts, but is in some instances (as the thyroid, and possibly 
the hyp ophy sis, and the pancreas) definitely contradicted. The fact that 
most of the endocrine products are more or less inert, when taken by 
mouth, probably explains much of the success of the pluriglandular therapy 
in the hands of the uncritical. 

5. But, you say, all these considerations and objections to pluri¬ 
glandular therapy are academic and beside the point. The whole mattef 
is: Does the patient improve or get well on, that is, because of the 
pluriglandular diet? Yes, that is the nub. We can throw the rationale 
of the therapy to the wind, provided the patient improves, and does not 
relapse when he receives our bill. All systems of healing point to sue- 


646 


ORGANOTHERAPEUTICS 


cessful cures, to the crucible of their clinics. But will you not agree that 
we must examine the crucible? Pluriglandular therapy as frank em¬ 
piricism is not to be wholly condemned, even in the twentieth century. 
But it increases the chances for 'post hoc fallacies, as few men are content to 
be mere puppets to the detail man. We try to think, at times. 

It is, perhaps, significant that thyroid extract (the one substance 
active per os) is so frequently an ingredient in the ready-to-serve pluri¬ 
glandular mixtures, just as alcohol and laxatives make up part of many 
otherwise inert patent medicines. For example, one manufacturing con¬ 
cern lists ten different pluriglandular mixtures, and seven of these are 
said to contain thyroid extract : 

“Orthophrenic” (thyroid, pineal, testes-ovary, prostate, cerebrospinal 
substance, activating substances). 

“Virilogenic” (anterior lobe, adrenal cortex, thyroid, testes, prostate, 
activating substances). 

“Galactagogue” (mamma, placenta, posterior lobe, thyroid, activating 
substances). 

“Morphogenic” (thyroid, adrenal, pituitary, pineal, thymus, activating 
substances). 

“Catabolic” (thyroid, posterior lobe, adrenal medulla, sperminum, ac¬ 
tivating substances). 

“Feminilogenic” (pituitary, adrenal, thyroid, corpus luteum, ovary, 
mamma (virgin), activating substances). 

“Osteoplastic” (thyroid, pituitary, parathyroid, adrenal medulla, thy¬ 
mus, activating substances). 

We are not informed what the “activating substances” are, except in 
the case of the thyroid, where it is said to be iodids. The use of these 
mixtures thus amounts practically to dosage of the patient with thyroid 
extract and potassium iodid. 

Experimental versus Clinical Organotherapy.—Despite the minor 
difference in species in the kind and severity of symptoms induced by 
specific endocrine pathology, and minor species differences in the effects of 
organotherapy, it is a striking thing that in all securely established facts 
of endocrine diseases and therapy, there is a practically complete parallel 
between the experimental mammal and man. We need mention only the 
thyroids, the parathyroids, the gonads, the pancreas. This fortunate fact 
rendered possible the rapid advance in the analysis of endocrine diseases 
in the last fifty years. This fact also tends to render the laboratory in¬ 
vestigator skeptical in relation to therapeutic results on man, that cannot 
be duplicated in the laboratory, especially if the clinical reports include 
such variables as guessing the diagnosis, several synchronous therapies, 
and inadequate controls in the way of the natural history of the disease. 


GENERAL PRINCIPLES OF ORGANOTHERAPY 647 

The clinician, on the other hand, perhaps knowing less intimately the 
evidence for the unity of life and organ function in mammals, is apt to 
become impatient with the strictures of the laboratory worker, and under¬ 
value the significance of experimental data in the analysis and cure of 
human ills. “After all,” they say, “the final arbiter is the crucible of the 
clinic.” But in so far as the clinic is or can be a crucible, it is identical 
with the crucible of laboratory research, and it is only after repeated re¬ 
fining that either crucible yields pure gold. The following seems obvious: 
(1) certain nervous manifestations of endocrine pathology, especially in 
the group of consciousness, may differ in man and the dog, and the labora¬ 
tory man must admit that conscious nervous manifestations cannot at 
present be studied with accuracy in the experimental animal. For ex¬ 
ample, there is nothing definitely known in the spayed bitch identical 
with the neurocirculatory disturbances of the spayed woman. When the 
internist reports that these neuroses of the premature menopause in his 
patients are ameliorated by ovarian therapy, the laboratory man has noth¬ 
ing to say, except the very obvious remark that nervous symptoms, es_- 
pecially in women, are often profoundly influenced by suggestion. The 
menstruation phenomena in women are not completely duplicated in the 
rut of the lower mammals. But as regards the other really objective find¬ 
ings of gonadeetomy and gonad therapy after castration there is no quar¬ 
rel between the clinician and the physiologist. 

Both groups must also admit the possibility of differences in actual 
physiological effects of organotherapy per os in man and the laboratory 
animals. As pointed out above, hormones given by mouth must pass 
the following obstacles before reaching their field of action (the blood 
and tissues) : the destructive action of the digestive juices, the destructive 
action of the intestinal bacteria, and exclusion or destruction by the in¬ 
testinal mucosa. So far as we know the digestive ferments are identical 
in all mammals, but there may be species differences in intestinal flora 
and intestinal permeability. Such differences, however, must be demon¬ 
strated, not merely assumed. 

A Complete Organotherapy Probably Not Attainable. —In the normal 
animal, hormone equilibrium is balanced by delicate chemical and nervous 
processes. When this equilibrium is upset by disease, it is probably im¬ 
possible to restore complete balance by our relatively crude methods of 
organ extract administration. It must not be forgotten, however, that 
we are aided by the wonderful plasticity and capacity for readjustment 
on the part of the organism, at least under many conditions. Even our 
most successful organotherapy (the thyroid) is merely a physiological 
control, not a cure, for when the therapy ceases the malady returns. When 
the malady does not return, sooner or later, when the organotherapy is 
stopped, we have merely tided the patient over a period of temporary 
depression of the gland involved, a form of gland “rest cure.” 


648 


ORGAHOTHERAPEUTICS 


THE THYROID 

The employment of thyroid in human medicine in cases of congenital 
absence, atrophy, or destructive lesions in the gland is a typical case of 
hormone therapy. It is also in reality our only well-established case of 
successful organotherapy. The marked result with this organ has been 
the main impetus and guide in the attempts to work out an organotherapy 
for the other endocrine glands. Th^ thyroid produces a substance or 
substances of specific physiological importance, stable in vitro, not de¬ 
stroyed by the digestive juices or the bacteria of the alimentary canal, 
and absorbed in active form into the blood. The functions of the gland 
may be partly replaced by the administration of the gland. So well 
established is this principle that conditions of the thyroid can be diagnosed 
in part from the effects on the body of the administration of the gland. 

The administration of the thyroid in organotherapeutics is based partly 
upon clinical and partly upon experimental work. The latter preceded the 
former, but the two methods have been closely combined, each reacting 
upon the other. The gland was not employed in medicine until a ra¬ 
tional basis for its use had been established experimentally; empiricism 
had no part in its introduction. 

The most important steps in our knowledge of the thyroid are the 
following: (1) the demonstration (by Schiff, Riverdin, Kocher, and 
others) that extirpation of the thyroid in adults leads to a series of dis¬ 
turbances designated by the term cachexia strumipriva, or myxedema; 
(2) the experimental production of cretins by removing the thyroid in 
young animals, and the recognition of sporadic and endemic cretinism 
in man as due to hypothyroidism; (3) the demonstration that the symp¬ 
toms of hypothyroidism can be partly controlled by thyroid administra¬ 
tion (Ewald, Baumann, Magnus-Levy, Pick and Pineles, Murray, Howitz, 
Mackenzie, Fox, Kocher, and others) ; (4) the discovery of the thyro- 
iodin and the subsequent studies of specific thyroid chemistry (Baumann, 
Oswald, Hunt, Marine, Koch, Kendall) ; (5) the demonstration of a re¬ 
lation of thyroid physiology to the diet (Watson, Hunt, Marine, Burget, 
Bensley) and possibly to infectious processes (McCarrison, Rosenow) ; 
(6) the studies of the possible control of thyroid activity through secre¬ 
tory nerves and circulatory changes (Asher, Watts, Cannon, and others). 

From the standpoint of clinical medicine some of the most impor¬ 
tant problems in thyroid physiology remain yet unsolved, namely, the 
cause and significance of the thyroid changes in so-called toxic goiter in 
man, and the cause of endemic goiter. 

Function of the Thyroid.— The thyroid develops from the epithelium 
of the branchial clefts of the embryo. The embryological anlage of the 
thyroid is thus similar to that of the parathyroids and the thymus gland. 


THE THYKOID 


649 


In the adult normal animal the thyroid is made up of acini of cuboidal 
cells with the thyroid colloid filling the center of the lumen. In mammals 
this adult structure begins to appear at or a little before birth. In early 
intra-uterine life there is no colloid or definite arrangement of the cells 
into acini. 

The colloid is obviously a cell product (cell degeneration or cell secre¬ 
tion). But its relation to the gland function is not yet clear. Bensley has 
succeeded in staining an intracellular thyroid colloid. This colloid is 
most abundant in the region of the cells adjacent to the lymph-vessels and 
blood-vessels. It is usually held that the colloid in the lumen of the 
acini represents a storage state of the physiologically important internal 
secretion, which, according to the needs of the body, becomes changed, is 
reabsorbecT by the cells, and passes into the blood-stream. 

The blood and lymphatic supply to the thyroid is very abundant, so 
that the blood flow through the gland per mass of tissue is greater than 
in any other organ in the body. Manley and Marine have shown that a 
piece of thyroid transplanted in other regions of the body stimulates the 
development of a similar extraordinary blood supply. The great vas¬ 
cularity of the thyroid is therefore intimately related to its specific 
function. 

Significance of the Thyroid Innervation.—Branches from the cervical 
sympathetic nerves pass along the thyroid vessels to the gland. These 
thyroid nerves have with certainty a vasomotor function. Their stimula¬ 
tion causes primary vasoconstriction of the gland, and this is followed 
by vasodilatation at the end of the stimulation. The question whether 
there are also true secretory fibers in the thyroid nerves has been at¬ 
tacked by diverse methods without as yet yielding conclusive results. 
Asher and Black, also Ossakin, report that stimulation of the thyroid 
nerves increases the excitability of the depressor reflex mechanism, due 
to an increased thyroid secretion thrown into the blood. Babe, et al., found 
that the stimulation of the nerves reduces the iodin content of the gland, 
and this was confirmed by Watts, but the latter investigator also found 
that identical decreases in iodin were induced by mechanically produced 
circulatory changes (temporary vasoconstriction) in the gland. Watt’s 
findings are questioned by Van Dyke. Cannon reports that a successful 
union of the phrenic nerve with the cervical sympathetic induces some 
of the symptoms (nervousness, exophthalmos, increased metabolism) of 
thyroid hypersecretion, owing to the continuous respiratory nervous dis¬ 
charges from the phrenic acting on the gland cells. The fact itself is 
contradicted by Troell, but if it shall be proved correct, as reported by 
Cannon, the excessive thyroid activity may be due to circulatory rather 
than secretory nerve disturbances. Cannon also finds that stimulation 
of the thyroid nerves produces an electrical change in the thyroid similar 
to that induced in muscle, or in nerve when thrown into activity. This 


650 OKGANOTHERAPEUTICS 

he interprets as proving a direct secretory nerve action. However, Schafer 
has reported similar electrical changes in the mammary gland on injec¬ 
tion of pituitrin, and it is now demonstrated that pituitrin causes, not 
milk secretion, hut merely a discharge of the milk present in the duct 
systems by contraction of the duct musculatures. Moreover, the electrical 
response in the thyroid, as reported by Cannon, was sometimes positive 
and sometimes negative. It does not seem possible at present to interpret 
both of these effects as due to an increased secretory activity. Moreover, 
denervation of the thyroid in normal animals does not produce hypo¬ 
thyroidism, and transplanted fragments of thyroid appear to function in 
a normal manner without nerves. Cannon, et al ., also report that stimula¬ 
tion of the thyroid nerves leads to a temporary acceleration of the de- 
nervated heart. They interpret this heart acceleration as due to an 
increased thyroid secretion. This interpretation is at present open to 
question. 

If secretory nerves are present they are certainly not necessary for the 
normal gland function. The control of the gland activity is, therefore, 
essentially a humoral one, as indicated by the. great vascularity. But the 
question of thyroid secretory nerves is, nevertheless, one of great prac¬ 
tical importance in relation to the cause and control of possible hyper¬ 
thyroidism. 

Chemistry of the Thyroid.—The older investigators reported the 
presence in thyroid of albumins, nucleoproteins, albumoses, leucin, xanthin, 
hypoxanthin, lactic and succinic acids, etc. In glands which have under¬ 
gone cystic degeneration the finding of mucin, cholesterin, methemo- 
globin, bile pigments, etc., is reported. 

Iodin .—Since the discovery, in 1895, by Baumann, of iodin in the 
thyroid, interest in the chemistry of the gland has centered largely around 
this element, and the substances with which it is in combination. 

The amount of iodin in the thyroid, not only of man, but of the lower 
animals is extremely variable, being influenced by age, character of the 
food, locality, the physiological conditions of the thyroid and many other, 
for the most part unknown, factors. The thyroids of infants and of 
newly born animals contain less iodin than adult thyroids; in fact, it 
cannot be detected at all in many cases, at least not by the use of usual 
quantities of the gland, and by the usual methods. But the same is true 
in many instances of the thyroid of adults and, to all appearance, nor¬ 
mal animals. Aschbacher gives the average amount of iodin in the 
human thyroid between the ages of twenty-five and thirty as 8.98 milli¬ 
grams ; it is less both in youth and old age. The percentage based on 
the weight of the dry gland varies from 0 to 0.4 or 0.5. Extreme varia¬ 
tions both in the total amount and in the percentage occur. The thyroids 
of salt-water fish contain three times the amount of iodin usually present 
in the mammalian thyroids. In some of the marine invertebrates iodin 


THE THYROID 


651 


is present in greater quantities in some of the cutaneous and excretory 
structures where the iodin cannot have the physiological significance it 
has in the thyroid of the vertebrates. 

The nature of the physiologically active iodin complex in the thyroid 
is unknown, notwithstanding the large amount of work which has been 
devoted to the problem. The form is specific for the thyroid; no other 
iodin compound is known which has the specific physiological properties 
of the thyroid substance or hormone (von Fiirth, Schwartz, Koch, Mac- 
Lean, Hunt and Seidell). It is known to be united in some way to the 
proteins, probably to one or more of the amino-acid constituents of these 
(Koch, Kendall, Cameron). 

Baumann isolated a specific hut ill-defined iodin compound from the 
thyroid, one which has at least many of the specific properties of the 
gland substance itself. He named this substance “iodothyrin.” 

Oswald isolated, at least approximately, the protein with which the 
iodin is combined. He named this protein “thyroglobulin”; it was found 
to constitute one-third to one-half or more of the weight of the dry gland. 
The iodin content varied from 0 to 0.86 per cent, or more. Oswald be¬ 
lieved this thyroglobulin, if it contained iodin, to represent the true active 
principle of the thyroid; Baumann’s iodothyrin could be obtained from it 
by hydrolysis. 

Oswald also isolated an iodin-free protein having the properties of a 
nucleoprotein, but this protein did not have the characteristic physiological 
thyroid action. 

F. C. Koch found that, as determined by the acetonitril test of Hunt, 
the thyroglobulin as well as the metaprotein fraction of the thyroid re¬ 
tained the full physiological activity of the entire thyroid. Further hydro¬ 
lysis into iodothyrin, and primary or secondary albumoses shows a gradu¬ 
ally decreasing activity, while the amino-acid fractions show little or no 
physiological activity, although they retain some of the iodin. The 
thyrometaprotein of Koch contains three times the percentage of iodin 
found in the entire thyroid, yet it shows no greater physiological activity 
than the dried thyroid. The relation of the iodin to the physiological ac¬ 
tivity of the thyroid thus appears to he a direct one. Hunt has reported 
that Kendall’s thyroxin is less effective than ordinary dried thyroid as 
determined by the acetonitril test. 

Thyroxin .—Kendall has isolated and analyzed a crystalline compound 
(CiiH 10 O 3 Kl 3 ) from the thyroid, having three molecules of iodin fixed 
in a protein derivative almost identical with tryptophan. This substance 
is called “thyroxin.” Kendall thinks it is the active thyroid hormone. 
On the whole, the action of thyroxin parallels that of crude thyroid extract 
in man and animals that have some thyroid gland left. It has not been 
proved that thyroxin is effective in absolute cretinism. This would be 
the crucial test of the true hormone nature of thyroxin. The thyroxin 


652 


ORGANOTHERAPEUTICS 


can be given hypodermically or intravenously. As measured by the effect 
on the basal metabolism on hypothyroid patients, the influence of a single 
injection of thyroxin is in evidence from four to seven weeks after an 
initial latent period of two to four days. The quantity of thyroxin 
obtainable from the thyroid is very small. Not all the iodin in the thyroid 
appears to be combined with thyroxin. Kendall estimates that there are 
14 milligrams of thyroxin in the body tissue (man), exclusive of the 
thyroid. Plummer estimates that the normal human adult uses up from 
0.5 to 1.0 milligrams thyroid hormones per day. Hence, the normal 
thyroid secretion should be at that rate. 

Relation of the Iodin to Physiological Activity of the Thyroid.— 
Baumann’s discovery of iodin in the thyroid stimulated an immense 
amount of work and led to the accumulation of a large number of facts 
as to the occurrence of iodin in the thyroid of various animals, and in 
that of man, under various conditions, both pathological and normal. The 
fact that iodin can frequently not be detected in the thyroids of healthy 
individuals has led many to doubt whether this element is a necessary 
or important constituent of the gland (cf. Hunt and Seidell, Carlson and 
Woelfel). From almost the beginning there has been evidence, not very 
conclusive, however, that the activity of the thyroid when used as a drug 
is closely dependent upon its iodin content. Thus, Roos in three experi¬ 
ments upon dogs found that more nitrogen was excreted after the ad¬ 
ministration of thyroid rich in iodin than after that of thyroid containing 
little iodin. Oswald, in two experiments, also found thyroglobulin rich 
in iodin to cause a greater excretion of nitrogen than did thyroglobulin 
poor in iodin. Marine and Williams found in two experiments that feed¬ 
ing thyroid containing a larger percentage of iodin caused a greater loss 
of weight in dogs than did a preparation containing a smaller percentage. 

Hunt, and Hunt and Seidell, in extended series of experiments, in 
which the effect of thyroid upon the resistance of animals to certain 
poisons was determined, found a close parallelism between the physiological 
activity of the thyroid and the iodin content. They also found that the 
iodin which accumulates in the thyroid after feeding iodin compounds is 
present in an active form, that is, in the form characteristic for the 
thyroid. In the same species large thyroids (goiter) contain a smaller 
percentage of iodin than small thyroids, and correspondingly expressed 
juice from large thyroids exhibits less physiological activity than that 
from small thyroids. 

Although further clinical tests are desirable, the above experiments 
offer almost conclusive evidence that the therapeutic value as well as the 
toxic action of thyroid preparations is directly proportional to the iodin 
content (Kocher). It is well established that feeding iodin in any form 
leads to a rapid increase in the iodin in the thyroid, but. it is not known 
whether the iodin thus stored is immediately incorporated as the physi- 


THE THYROID 


653 


ologically active thyro-iodin compound. Possibly the thyroids may store 
iodin outside of this compound, for example, in the colloid. Kendall has 
obtained inactive iodin fractions from the thyroid. 

Several writers have called attention to the variation in the iodin 
content of commercial thyroid preparations: Hunt and Seidell found the 
preparations on the American market to vary from 0.095 to 0.38 per 
cent. The average was approximately 0.2 per cent. 

It is thus evident that the commercial preparations vary by as much 
as 400 per cent. Such variations in the strength of most drugs would be 
considered intolerable, and there can be little doubt that more satisfactory 
therapeutic results would often be obtained if the thyroid preparations 
were more uniform in strength. That lack of uniformity does not cause 
more inconvenience is due largely to the fact that thyroid medication 
must, by its nature, be peculiarly individual: the dose must be governed 
by the degree of thyroid deficiency of the patient, and this can only be 
determined by trials with different doses. 1 When, however, the proper 
dosage of a certain preparation in an individual case has been determined, 
it would be distinctly advantageous to be able to continue the same dosage 
if a fresh supply were prescribed. At present, even if the same firm’s 
preparation were prescribed, the second order might be several times as 
active as the first. Hence, it would be very desirable for the pharmacopeia 
to fix a standard iodin content for the official preparation; a standard of. 
0.2 per cent would seem reasonable (Hunt and Seidell). This iodin con¬ 
tent must, of course, represent the physiologically active thyroid sub¬ 
stance, and not the addition of other organic or inorganic iodin. For that 
reason the chemical standardization by means of the iodin percentage 
should be supplemented or controlled by physiological standardization 
(the acetonitril method of Hunt, the cretin method of Basinger or quan¬ 
titative determination of the thyroxin content). 

The iodin in the thyroid is both in the colloid and in the cells. There 
is a fairly uniform ratio of distribution, two-thirds being in the colloid 
and one-third in the cells (Tatum, Van Dyke). 

Relation of the Thyroid to Diet.—It has been shown by Watson and 
Burget (on the rat), Marine and Lenhart, and Gaylord and Marsh (for 
the salmonoid fishes), and Bensley (for the opossum) that a high or other¬ 
wise abnormal protein diet induces thyroid hyperplasia and marked en¬ 
largement of the gland. But this appears not to be true for the guinea 
pig (Loeb). In the case of the brook trout this hyperplasia followed 
feeding with mammalian liver or uncooked animal protein, and was 
promptly stopped by feeding with fish or cooked meat. McCarrison was 
able to induce thyroid hyperplasia in rats by feeding extracts of feces 

1 I have met with one case of hypothyroidism with intense intolerance to any 
form of thyroid medication. This is therefore a factor in dosage in rare instances.— 
Editor. 



654 


OKGAJST OTHERAPEUTICS 


from goiter patients. But we are not permitted to generalize from these 
observations, although they are both interesting and important, for high 
protein diet, or feces from goiter (toxic) patients fails to induce these 
thyroid changes in other species (cat). Evidently the thyroid stability or 
factor of safety varies greatly in different species. 

Feeding meat is said to reduce the iodin content of the thyroid. This 
may be a factor in the hyperplasia. 

Feeding thyroid, food rich in iodin or iodids, tends to increase the 
colloid in the thyroid, as well as the total iodin content in the gland. 
Thyroids in the process of compensatory hypertrophy seem to form an 
exception (Loeb). 

Hunt found that mice fed on oatmeal or on oatmeal and liver showed a 
much greater resista'hce to acetonitril than mice of the same litter fed 
on eggs, crackers and milk. He ascribes this difference to a greater 
stimulating action of the oatmeal and the liver diets on the thyroid 
gland. 

Prolonged starvation or vitamin A-free diets lead to degeneration 
and atrophic changes in the thyroid (Jackson, Tsjuji). 

Secretion versus Detoxication.—Bensley and others claim to have . 
identified the thyroid secretion in the cells by microchemical methods 
much in the same way as the secretion granules or pro-secretion of the 
digestive glands have been brought out by staining. But the presence of 
the secretion as a normal element in the body fluids has not been demon¬ 
strated. Our strongest evidence that the thyroid works by the mechanism 
of an internal secretion rather than by processes of detoxication is the 
result of thyroid organotherapy in experimental and clinical hypothyroid¬ 
ism. These results are capable of no other interpretation. But this does 
not exclude detoxication processes in the thyroid; in fact von Cyon’s 
theory is partly true. Because of the special affinity of the thyroid for 
iodin, iodin compounds of all kinds—including the more or less toxic in¬ 
organic iodids—are taken out of the body fluids and turned into the less 
toxic thyroglobulin. But this work can be performed by the kidneys as an 
elimination process, and at any event it is of secondary importance in 
thyroid physiology, for much of the thyroid function can be taken by 
the dried and dead thyroid product. 

The Thyroid Secretion and Body Fluids.—Probable as it seems from 
experimental and clinical data that the normal thyroid yields a secretion 
to the body fluids, yet it must be admitted that this secretion has not yet 
been demonstrated in the blood or the lymph, even in the lymph taken 
directly from the thyroid gland. The colloid observed, by histological 
methods, in the thyroid lymphatics is probably an artefact. The acetoni¬ 
tril test on normal blood of men and animals is negative (Hunt, Carlson 
and Lussky). Even in cases of blood from exophthalmic goiter patients, 
the method yields inconclusive results. Trendelenburg reports that the 


THE THYROID 


655 


blood of thyroidectomized cats yields a positive acetonitril test—a fact 
which seems to question the validity of the test itself. 

Basinger repeatedly transfused blood of normal rabbits into cretin 
rabbits without observing any effects on the cretin conditions; but when 
similar transfusions were made into the cretins of blood from rabbits fed 
varying quantities of commercial thyroid, the cretin condition was in¬ 
fluenced in the same manner as by feeding thyroid. 

It is altogether probable that the thyroid secretion is present in normal 
blood, but in too small concentrations for detection. This is indicated 
by some work of Woelfel and Luckhardt. These investigators find that 
when blood from dogs with high iodin content of thyroid is transfused 
into dogs (previously bled dry) with low iodin content of the thyroid, 
the percentage of iodin in the thyroid of the latter is increased. This 
seems to show that there is a balance or equilibrium between the stored 
thyroid secretion in the gland and the circulating thyroid secretion in 
the blood. This gives us hope that the question of thyroid secretion in 
the various types of thyroid hyperplasia may yet be solved by blood 
analysis. The presence of thyroglobulin in lymph and blood coming from 
the thyroid gland has recently been demonstrated (Hektoen and Carlson). 

Relation of the Iodin to Histological Structure of the Thyroid.—If 
iodin is a necessary constituent for normal thyroid function it would seem 
that it would be equally necessary for normal thyroid structure. Never¬ 
theless, in exceptional cases in most animals and, as a rule, in some 
species, iodin in structurally normal thyroids is either absent or so small 
in amount that it cannot be demonstrated by our best chemical tests. 
The most significant findings in the relation of the iodin to thyroid struc¬ 
ture are the observations of Marine, Bensley, Loeb, and others, namely, 
that most types of thyroid hyperplasia can be arrested and converted 
into a colloid or resting state by the administration of iodids in any form. 
It is now generally agreed that the simple thyroid hyperplasia of endemic 
goiter, adolescence, etc., can to a large extent be prevented or controlled 
by small quantities of iodids. We are not permitted to conclude from this 
fact that the hyperplasia which is controlled in this way is due to lack 
of iodin in the food or in the body. This arrest of hyperplasia may be a 
drug action of the iodin, or an evidence of a detoxicating role of the 
thyroid, as suggested by von Cyon, the excess of inorganic or toxic iodin 
being converted by the thyroid into a non-toxic or less toxic form. Accord¬ 
ing to Bensley, the thyroid hyperplasia induced in the opossum by ex¬ 
cessive protein diet is not arrested by iodids. 

According to Jones, and Jones and Tatum, increasing the iodin con¬ 
tent of the thyroid increases the stainability of the thyroid colloid, so that 
the amount of iodin in the gland can be in part determined by the reaction 
of the colloid to Mallory’s connective tissue stain. 

The specific affinity of thyroid tissue for iodin is retained in certain 


656 


ORGAN OTHERAPEUTICS 


stages of malignant growths of the thyroid, primary and secondary. 2 
Whether the iodin complex in these* thyroid tumors represents the active 
thyroid hormone has not yet been established. 

Sweet and Ellis report that removal of the external function (pan¬ 
creatic digestion) of the pancreas leads to an increase of iodin and col¬ 
loid in the thyroid glands. 

Relation of Thyroid Hyperplasia to Thyroid Neoplasm.—Thyroid 
hyperplasia predisposes to thyroid neoplasm. In dogs, malignant growths 
of the thyroids with typical bone, lung, and liver metastases are not in¬ 
frequently found on the basis of an old goiter. We have never seen 
them start from a normal thyroid. Regenerating thyroid tissue (compen¬ 
satory hyperplasia) may show powers of invasion like cancer (Loeb). 

The line of demarcation between simple hyperplasia and malignancy 
would seem to be metastatic growth. Yet, something like metastatic 
spreading growths appears to be a normal phenomenon in the thyroid 
of fishes, where the glands are not surrounded by a connective tissue 
capsule (Gudernatsch). This has led to contradictions and confusions 
in the interpretations of the thyroid hyperplasia or thyroid cancer so com¬ 
mon in salmonoid fishes, especially under domestication. Marine and 
Lenhart regard these thyroid growths as simple hyperplasia, since they 
respond to the same measures that modify simple thyroid hyperplasias in 
mammals. Gaylord and Marsh, on the other hand, regard all stages of 
this hyperplasia as malignant neoplasm. This appears to the writer an 
extreme position. If this view is tenable for fish, it should be equally 
tenable for mammals, in which case thyroid hyperplasia in man and other 
mammals becomes a cancer problem. Gudernatsch has pointed out that 
the metastases of normal fish thyroids do not cause destruction of ad¬ 
jacent tissue. The same is certainly true for simple thyroid hyperplasia 
in the higher animals. At the same time malignancy in the primary 
thyroid tumor is probably present sometime before metastatic growth 
occurs, so that a sharp line between simple hyperplasia and malignancy 
of thyroid growths cannot be drawn. 

Hyperthyroidism, Experimental and Clinical 

Toxic Goiter.—The effects of hypothyroidism, experimental and clin¬ 
ical, are clear; and their control is partly in our hands through organo¬ 
therapy. This cannot be said of the causes and effects of hyperthyroidism 
—if, indeed, there is such a thing as continued hyperactivity of the thyroid 
with attendant symptoms of disease. Hyperplasia of the thyroid gland 
occurs in man and animals under many conditions. We have seen that 
in some animals it may be experimentally induced by the diet. In 

3 Some malignant growths of the thyroid are associated with the clinical picture 
of exophthalmic goiter.—Editor. 



THE THYROID 


657 


women there frequently occurs what may be called a strictly physiological 
hyperplasia at puberty, at menstruation, and during pregnancy, although 
some of the enlargement of the thyroids at these periods may be simply 
due to increased vascularity. The period of active growth of simple or 
benign goiter is really a period of hyperplasia. According to Marine, 
a colloid goiter represents a relatively resting stage of a previous hyper¬ 
plasia. Finally, in so-called toxic goiter, or Basedow’s disease, there is 
usually proliferation of the thyroid cells, increase in gland volume and 
gland vascularity, with decrease in gland colloid. It may be considered 
as a general rule that the amount of colloid in the thyroid is inversely 
proportional to the rate of cell division and growth of the gland at any 
period. 

In moderately severe cases of Graves’ disease, Geyelin reports that 
70 per cent of his cases showed a lowered sugar tolerance. Milder cases 
have normal blood sugar. Feeding thyroid to myxedematous patients 
may induce hyperglycemia. 

It must be noted, in the first place, that mere increase in cells and gland 
volume does not mean increased activity or increase in the secretion. A 
mere fraction of the normal thyroid suffices to meet the normal needs 
of the organism. This means that the thyroid under normal conditions 
does not work up to full capacity; hence, it should be possible to increase 
greatly the rate of thyroid secretion without increase in the number of 
cells. If, as seems probable, the thyroid activity is governed mainly by 
the blood, doubling the thyroid volume would no more increase the thyroid 
secretion than doubling the kidney volume would increase the quantity 
of urine. The reverse experiment has not been made, but we predict 
that when made, that is, when two healthy kidneys are successfully im¬ 
planted, say on the carotids in the neck, the sum total of the urine secreted 
by the four kidneys will be no greater than that secreted by animals’ 
own kidneys before the implantation. 

In the second place, gland cells in condition of active division and 
proliferation are probably not sufficiently differentiated to perform a 
highly specialized function. And, in the third place, we have as yet 
no reliable test, histological, physiological, or chemical, for the rate of 
thyroid activity, at least covering longer periods than ordinary crucial 
experiments. Yet, the commonly accepted theory to-day is that of Mobius, 
namely, that the thyroid hyperplasia in toxic goiter represents thyroid 
hypersecretion and that the hypersecretion is responsible for the toxic 
symptoms. 

This last theory is based mainly on three lines of evidence: (1) symp¬ 
toms similar to the syndrome of toxic goiter are produced in man by 
excessive thyroid administration; (2) patients with toxic goiter appear 
on the whole to be excessively sensitive to thyroid administration; (3) in 
many cases the symptoms of toxic goiter appear to be at least partly 


658 


ORGANOTHEKAPEUTICS 


controlled by surgical and medical measures that reduce the thyroid volume 
and presumably the thyroid activity. 

The most striking symptom of toxic goiter is the greatly accelerated 
metabolism. DuBois, Plummer and Boothby, Means, and others have 
shown that in severe cases this may be increased 75 per cent above normal, 
and an increase of 50 per cent in moderately severe cases is not uncom¬ 
mon. In mild cases the state of metabolism may be practically normal. 
DuBois thinks that some of the other symptoms (tachycardia, high blood- 
pressure, high temperature, nervousness) are in part secondary effects of 
augmented metabolism with the attendant increased production of heat. 
DuBois also showed that there is no conservative form of treatment of 
toxic goiter that reduces the metabolism rate to any greater degree than 
mental and physical rest. These measures may lower the rate more than 
10 per cent, while in some cases ligation of the thyroid arteries actually 
increased the rate of metabolism. 

Experimental hyperthyroidism has not yet been produced. There 
is no evidence that the rat, fish, and opossum thyroids of Watson, Marine, 
McCarrison, and Bensley secreted in excess. It is true that excessive 
thyroid feeding, especially in man, duplicates most of the symptoms of 
exophthalmic goiter, but the same effects would probably be produced 
by any other substance that had a similar effect on the metabolism rate. 
It is biologically significant and clinically important that, of all animals 
so far studied, man is the most susceptible to the deleterious effects of 
thyroid feeding. The attempt of Cannon to induce hyperthyroidism by 
union of the phrenic and cervical sympathetic nerves has already been 
referred to. 

There are not wanting other interpretations of the nature of thyroid 
hyperplasia, especially in toxic goiter. The most important are the per¬ 
verted secretion ‘theory and the compensatory hypertrophy theory, espe¬ 
cially as elaborated and.upheld by Marine. According to Marine, the 
hyperplasia in goiter is a response of the thyroid to an increased need 
of the body for the secretion in consequence of some disarrangement in 
the general metabolism; in fact, despite the increased secretion in toxic 
goiter, there may be an actual thyroid deficiency owing to the greater 
need for the secretion. On this theory, there is room for at least a careful 
experimental thyroid organotherapy in toxic goiter; and, in fact, favorable 
results from thyroid feeding in toxic goiter have been obtained by com¬ 
petent clinicians. If the thyroid hyperplasia of toxic goiter is not pri¬ 
mary, but compensatory in nature, we expect thyroid feeding to reduce the 
hyperplasia. Loeb has shown that the true compensatory hyperplasia 
following extirpation of the larger part of the thyroids is prevented by 
thyroid feeding. It is not prevented by iodids, thymus, or tethelin 
feeding. 

The nature of the thyroid hyperplasia in toxic goiter is, of course, 


THE THYROID 


650 


bound up with the question of the cause of the hyperplasia. It will 
probably be found that we are dealing with a complex of causes (abnormal 
diet, deranged metabolism, specific and non-specific infections, nervous 
disarrangements, etc.). That the hyperplasia in experimental animals 
is primarily due to changes in the blood appears to be shown by the experi¬ 
ments of Manley and Marine. The transplant of a normal thyroid into 
an animal with active thyroid hyperplasia becomes hyperplastic, and vice 
versa. Pups from bitches with active thyroid hyperplasia are born with 
hyperplastic thyroids or goiter (Carlson). 

The interpretation of the nature of thyroid hyperplasia in toxic goiter 
is further complicated by the fact that, in many of the lower animals, 
thyroid hyperplasia, histologically identical with that of toxic goiter in 
man, is present without any other of the Basedow’s syndrome. In fact, 
spontaneous Basedow as well as spontaneous cretinism is very rare, though 
apparently not unknown, in animals below man. 

The justification for this rather lengthy discussion of hyperthyroidism 
in a chapter on Organotherapy is our desire to point out that the existence 
of actual thyroid hypersecretion with consequent symptoms of disease is 
still in question; also that it behooves clinical and laboratory workers to 
test anew prevalent theories, in the hope of reaching a clearer knowledge 
and a better control of a very serious malady, be it through organotherapy 
or other measures. 

According to Marine and Baumann the excessive metabolism and fever 
following removal or serious trauma to the adrenal cortex is prevented 
by thyroidectomy. If this is true, it would seem that the thyroid gland 
is at least temporarily disturbed (increased secretion) directly by the 
withdrawal of the adrenal cortex hormones, or by toxins produced in 
other parts of the body in the absence of adrenal cortex function. 

Hypothyroidism in Childhood 

Cretinism.—The most marked effect of the removal of the thyroid in 
young animals and of its atrophy or injury in children is a cessation of 
growth and development, both physical and mental. The changes in 
the skeleton are especially marked; there is a cessation or retardation of 
the normal ossification of the cartilages. The epiphyseal ends of the long 
bones grow slowly, while the periosteal ossification may be normal or in 
excess. The extremities are relatively short and thick; the pelvis is small. 
This condition and the muscular degeneration are responsible for the 
protruding abdomen. Abnormalities in the growth of bone are largely 
responsible for the characteristic shape of the skull and thorax in cretins. 

If the thyroid deficiency does not occur until rather late in childhood, 
the above changes may be absent, and the hyperthyroidism may be evident 
only in a cessation of normal growth. 


660 


ORGAN OTHERAPEUTICS 


The hair on the pubis and in the axillae is scanty or absent, and the 
sexual organs are poorly developed; while puberty, if it occurs at all, 
is late. The skin in children is often myxedematous. Metabolism is 
much depressed (Bergmann, Mansfield, DuBois), and the oxygen ab¬ 
sorption and nitrogen excretion may be but one-half that of the 
normal. 

It is difficult, however, to distinguish between primary and secondary 
effects of injuries to the thyroid. The latter cause marked changes in 
the nutrition and metabolism, and these may be the immediate cause of 
some of the abnormalities now ascribed to the direct influence of the 



Fig. 1.—A Normal Rabbit and Two Absolute Cretins from the Same Litter. Age 
Three Months. Control rabbit 1.630 grams; cretins, 760 and 840 grams. (Basinger.) 

thyroid. There is evidence that hypothyroidism leads to increased growth 
of the hypophysis, the adrenals, and the islands of Langerhans in the 
pancreas. We cannot at present say whether or not these changes are 
compensatory in nature. The evidence seems to be to the contrary, at 
least as regards the changes in the hypophysis. 

The effects of thyroid insufficiency upon mental development are no 
less striking than those upon physical development; the patients are apa¬ 
thetic, the expression is stupid, and idiocy frequent. There is evidence 
of degenerative changes in many of the organs and especially the muscle. 
The fatty degeneration of the muscle is, at least in part, responsible for 
the feeble heart, muscular weakness, and characteristic “pot belly.” There 
is also decreased resistance to infection, and, strange to say, increased 
susceptibility to thyroid administration. 





THE THYROID 


661 



Complete thyroidectomy in experimental animals appears to prevent 
sexual maturation entirely, and thus leads to sterility. 

The cretin symptoms following complete thyroidectomy in the young 
but otherwise normal animal do not appear until late after the operation 
(three to six weeks or longer). 

Spontaneous cretinism is rare in the lower animals. In man it is 
sporadic as well as endemic, and in either case it may be congenital or a 
matter of gradual development after birth (primary atrophy, cystic or 
colloid degeneration). The physiological state of the maternal thyroid 
during gestation influences the thyroid of the fetus. Thus, if the mother 


Fig. 2.—Skin Lesions Developed in Thyroid-fed Absolute Cretins Five Months 
after Discontinuing the Thyroid Treatment. (Basinger.) 

has marked thyroid hyperplasia during pregnancy the offspring is born 
with enlarged thyroid; on the other hand, simple colloid goiter in the 
mother has no influence on the fetal thyroids. It is also reported that 
complete thyroidectomy in the mother leads to thyroid hyperplasia in the 
offspring. 

The thyroid hyperplasia of the young from mothers having active 
thyroid hyperplasia during pregnancy is probably not an instance of true 
inheritance, but a matter of fetal environment. The same conditions that 
induce the hyperplasia in the mother, acting through the blood, produce 
the same effect on the fetus. Hence it is primarily a humoral, not a 
nervous effect. But there may also be true inheritance factors in both 
simple and toxic goiter. 




G62 


ORGANOTHERAPEUTICS 


Hunter found that thyroidectomized sheep on starvation showed no 
starvation acidosis, hut they excreted more nitrogen than the controls. 
They showed no diminished oxidation, at least as regards purin catabolism, 
but the sugar tolerance appeared to be increased. Mansfield and Ernst 
state that there is no increased rate of protein catabolism in experimental 
fevers in thyroidectomized animals. According to Herring complete 
thyroidectomy in cats and rabbits has no effect on the epinephrin content 
of the adrenal glands unless parathyroid tetany develops, in which case 
there is a decrease in epinephrin. But in the cat, feeding large quan- 
tities of raw, ox thyroid increases the epinephrin content in the gland 
by more than a third; Miura states that thyroidectomy does not influ¬ 
ence alimentary and phlorizin glycosuria in the animal, but diminishes 
somewhat epinephrin glycosuria. Contrary to earlier reports (Lorand) 
thyroidectomy does not appreciably influence pancreatic diabetes. 
Yuschemko has described certain changes in the phosphorus and lipoid 
content of the blood and organs after thyroidectomy in animals. 

Hypothyroidism in the Adult 

•4 : 

% 

Myxedema.—Thyroid deficiency in the human adult is seen most 
typically in myxedema, which is characterized by physical and mental 
inertia, and by changes in the skin, depressed metabolism, etc. The skin 
is white and thickened, due to the growth of granulationlike tissue and 
an infiltration with a substance resembling mucin; the secretions are 
scanty or absent; the skin becomes dry and rough; the hair falls out. 
There are frequently abnormal sensations of taste, smell and hearing. 
The temperature is subnormal and the pulse slow and weak. There are 
diminished oxygen absorption and carbon dioxid secretion; there is a 
tendency to obesity, although the patients usually eat little. The metab¬ 
olism is depressed to a greater degree than in any other known condition. 

Lusk states that it is possible to explain the reduced temperature as 
due to disturbances in the nervous mechanism of temperature regulation, 
and that the lowered temperature may be an influence in reducing the 
metabolism of the cells. The coagulation time of the blood is stated 
to be shortened (Lidskey). 

The effect of thyroidectomy on adult animals is variable. True 
myxedema is rarely, if ever, developed. This leads one to question whether 
myxedema in man is pure hypothyroidism. Monkeys do not show con¬ 
ditions analogous to myxedema in human beings, at least for months or 
years after the operation (Munk, Kishi, Vincent and Jolly, Halpenny 
and Gun). Many adult animals show little change after the removal 
of the thyroid, although eczema, conjunctivitis, rhinitis and other indica¬ 
tions of catarrh of the respiratory passages, and especially emaciation and 
diminution in the number of red and increase in the number of white 


THE THYROID 


663 


corpuscles are common. There is lowered resistance to infection. Metab¬ 
olism may be depressed; carbohydrate tolerance is increased. Degenerative 
changes in the ovaries and testes have been described. 

Thyroid Administration in 
Hypothyroidism.—The most 
marked effects of the adminis¬ 
tration of thyroid are seen in 
cases in which the thyroid is 
absent or deficient, and it is 
upon the results in such cases 
that the therapeutic use of thy¬ 
roid is based. Fresh or dried 
entire thyroid has so far yield¬ 
ed as good or even better re¬ 
sults than various isolation 
products of the gland, such as 
thyroiodin, and thyroxin. 

Administered in appro¬ 
priate doses to cases of sporadic 
cretinism and infantile myxe¬ 
dema., there is at first a loss 
of weight, with improvement 
of the skin. Cyanosis dis¬ 
appears and the blood be¬ 
comes normal. Growth, both 
bodily and mental, recom¬ 
mences and may take an almost 
normal course. The hair 
grows rapidly and becomes 
glossy; the teeth and nails also 
grow. There is a distinct acceleration of metabolism. The mental 
improvement is most marked in young children. Similar results 
are obtained in cretinoid animals (Pick and Pineles, Basinger, and 
others). 

In complete absence of thyroid tissue no amount or duration of thyroid 
administration will bring the final growth up to the normal. Thyroid 
organotherapy is therefore not a complete substitute for the living organ. 
This is not surprising in view of the extensive degeneration found in 
practically all the organs in absolute cretinism. 

Many attempts have been made to stimulate growth in conditions 
other than cretinism by thyroid administration. Thus, it has been ex¬ 
tensively tried in idiots and backward children. It has been administered 
in cases of delayed union of fractures on the theory that it would hasten 
union by stimulation of the specific bone metabolism. 




Fig. 3.— Thyroid Deficiency in the Tadpole, a , 
hind leg of normal tadpole (total length 52 
millimeters; body length, 23 millimeters) 
showing normal cartilage and bone formation. 
5, hind leg of thyroidless tadpole (total length, 
80 millimeters; body length, 29 millimeters), 
showing defective cartilage and bone forma¬ 
tion. (Terry.) 


664 


OKGANOTHERAPEUTICS 


Administered to cases of myxedema of cachexia thyreopriva, the 
myxedematous condition largely disappears. There is a marked increase 


Weeks 2 4 6 0 10 12 14 16 IB 20 22 2*4 26 26 30 92 34 

Gm. 

2600 

2400 

2200 

2000 

isoo 

1600 

1400 

1200 

1000 

800 

600 

400 

ZOO 








































1 









• 













4 ) 




















































7 




A 

























































. 















































































Fig. 4A.—Growth Curves of Four Normal and Three Absolute Cretin Rabbits, 

Same Litter. (Basinger.) 


in metaholism. The excretion of nitrogen in the urine may he increased 
100 to 200 per cent. This increase results largely from the increased 



Fig. 4B. —Growth Curves of Four Normal Control Rabbits, Five Absolute Cretins, 
and Eight Absolute Cretins Fed Standard U. S. P. Thyroid Extract. (Basinger.) 


intake due to improved appetite, but there is usually a true loss of nitro¬ 
gen. There are no striking changes in the partition of the nitrogen in 

















































































THE THYROID 


665 


the urine. The consumption of oxygen may be increased 70 per cent. 
The temperature rises; the pulse rate is increased; there is usually a 
striking loss of weight due to the disappearance of the myxedematous 
infiltration and loss of fat. The entire metabolism is brought back to the 
normal level or raised slightly above the normal. The skin approaches 
the normal; sweating, which is usually entirely absent in myxedema, 
becomes possible. The hair grows again; menstruation reappears; the 
bowels become regular; the mental condition is much improved. These 
changes begin in three to four weeks, with the usual doses of thyroid. 

The first myxedematous patient treated with thyroid extract by Dr. 
Murray, beginning 1891, died in 1920. During these twenty-nine years 



Fig. 4C. —Growth Curves of Four Normal Control Rabbits, Two Absolute Cretins, 
and Six Absolute Cretins Transfused Repeatedly with Hyperthyroid Blood 
Serum. (Basinger.) 

the patient enjoyed ordinary good health, and the myxedema was kept 
under control by continuous thyroid feeding. 

The marked changes in the skin in cases of myxedema produced by 
the administration of thyroid have led to the extensive trial of this sub¬ 
stance in other abnormal conditions of the skin. 

Thyroid Feeding in Conditions of Mild Hypothyroidism —In addi¬ 
tion to the above conditions, in which there is obviously severe thyroid 
deficiency, there are a number of conditions of hypothyroidism of a less 
severe type. But it must be admitted that the diagnosis of hypothyroidism 
in “borderland cases” is at present very uncertain. Kocher states that 
man y cases which have been treated for anemia, chlorosis, scrofula, 
nervousness, and disturbances of menstruation, seem to him clearly to be 
cases of thyroid deficiency. He also calls attention to the cases in which 






































066 


ORGAN OTHERAPEUTICS 


children show retarded growth with no apparent cause. The favorable 
results following the administration of thyroid make the diagnosis of the 
condition clear. Many of the cases of mild thyroid deficiency show, 
according to Kocher, very definite symptoms, among the most marked 
of which is a feeling of inhibition preventing the subjects from accomplish¬ 
ing that which they desire. They are incapable of continued effort, such 
as reading, writing, and even speaking; they become shy and avoid society. 
They are indifferent to food, and neglect going to stool. Kocher states 
that improvement follows the administration of thyroid in such cases. 

Kocher mentions many other symptoms due, as the effect of thyroid 
treatment appears to show, to slight thyroid deficiency. Among these are 
fatigue from slight exertion, although muscular development is good; 
slight swelling of the eyelids, lips and cheeks; tendency to obesity, and the 
appearance of local accumulations of fat; swelling of the joints, so that 
patients frequently state that they suffer from gout or rheumatism; 
paresthesia, especially feelings of stiffness. Sometimes the skin has a 
yellowish tinge, suggesting chlorosis. Pigmentation of the skin is fre¬ 
quent, resembling that seen in pregnancy; the pigmentation in the latter 
condition may be due to relative thyroid insufficiency. The pigmentation 
often disappears under the influence of thyroid. Kocher raises the ques¬ 
tion whether the effect of the thyroid in such cases may not be due to 
an effect upon the suprarenals or other organs of internal secretion. 

Further changes in the skin and its appendages, upon which Kocher 
lays much emphasis, are dryness and coldness, with little tendency to 
sweating; the dryness of the hair and its tendency to fall out; the tendency 
of the nails to crack and of the teeth to caries. 

Kocher warns against ascribing more severe skin diseases to a condi¬ 
tion of hypothyroidism, although he states that eczema, ichthyosis, etc., 
are especially prone to occur where the nutrition of the skin is deficient 
as a result of hypothyroidism. 

Individuals with these mild degrees of hypothyroidism are sensitive 
to the cold. The coldness of the skin is due to sluggish circulation, which 
is also evident from the weak pulse. 

Kocher states that marked improvement occurs in such cases as the 
above within a week or ten days (sometimes even in twenty-four hours) 
after beginning the administration of thyroid. Similarly beneficial results 
are stated to occur in the aged, when symptoms of thyroid hypofunction 
result from the gradual deterioration of the gland, and in pregnancy, 
when the thyroid may be unable to meet the increased demands made 
upon it. 

Various, chronic diseases and intoxications (tuberculosis, alcoholism, 
and sometimes syphilis) may injure the thyroid, so that a mild degree 
of hypothyroidism results; here again thyroid medication may be of 
benefit. 


TIIE THYROID 


667 


Stoeltzner states that rudimentary forms of infantile myxedema 
characterized by cessation of growth, excessive fatness, etc., are not 
uncommon; they sometimes follow infectious diseases or traumatism. 
In such cases, thyroid causes some improvement. Simpson reports favor¬ 
able results in many cases of infantile wasting. 

Effects of Thyroid Administration in Normal Individuals.—Similar 
effects upon metabolism, but less marked and less constantly obtained, are 
produced when thyroid is administered to normal individuals and to nor¬ 
mal animals. The effect in normal animals is largely a question of 
quantities of thyroid given, and of the species, man being the most sus¬ 
ceptible. And there are great individual variations in the susceptibility 
to thyroid among apparently normal persons. The absorption of oxygen 
and the excretion of carbon dioxid may be increased 10 to 20 per cent, 
although in some cases there is no increase. The excretion of urinary 
nitrogen may be increased 20 to 50 per cent; usually it is less, much 
depending on the character of the diet. The change in nitrogen metab¬ 
olism usually occurs first; that in total metabolism occurs later (in the 
course of two to three weeks). Increased destruction of protein cannot 
always he prevented by the administration of non-nitrogenous food. 
Hewitt reports, however, that fresh thyroid, fed to adult rats in doses 
of 0.25 grain or less per day, leads to increased food consumption and 
body weight, while larger doses have the opposite effect. Large doses 
of thyroid or thyroxin decrease the rate of growth in young rats and 
rabbits, cause hypertrophy of the heart, liver, kidneys and adrenals 
(Hoskins, Cameron and Carmichael). Feeding thyroid to young rabbits 
stimulates the hone marrow (Lim). Thyroid feeding in rats is said to 
produce tetany (Cameron and Carmichael), and a decreased nitrogen 
and gaseous metabolism (Kojima). 

The excretion of phosphorus and of sulphur is said to he increased. 
There is, in man, usually a distinct increase in nervous excitability with 
attendant circulatory and other disturbances. Gudematsch found that 
feeding thyroid to frog tadpoles greatly accelerates the metamorphosis, 
while growth is actually retarded. This does not appear absolutely specific 
for the thyroid substance, as Morse and Swingle obtained the same result 
with iodized blood albumin, and Abderhalden with thyroid protein 
hydrolyzed down to the amino-acid stage. According to Lim thyroid 
feeding stimulates general cell mitosis in the tadpole. 

Ho other organ has such marked effects upon metabolism, and many 
attempts have been made to utilize these effects therapeutically. 

Indications for Use of Thyroid.—The indications for the use of 
thyroid are clear in those cases in which there is a deficiency in the normal 
secretion; in other cases, however, its administration must be largely 
determined empirically, and it must first be shown that the type of 
increased metabolism induced by thyroid feeding is really beneficial in 


668 


ORGANOTHERAPEUTICS 


cases where there is not depression of metabolism due to thyroid deficiency. 
The mode of action of thyroid upon metabolism is obscure. Some believe 
that it stimulates the cells directly to increased activity; whereas others 
think that the effect is primarily upon various parts of the nervous system, 
the stimulation of which causes increased activity which results in in¬ 
creased metabolism. In support of the latter view, Anderson and Berg- 
mann state that there is no increase in the carbon dioxid output when 
thyroid is administered to a person kept in a perfect quiet. 

That excessive amounts of thyroid do increase nervous irritability 
is generally accepted on the basis of observations in Graves’ disease and 
the results of administering large doses of thyroid. Magnus-Levy be¬ 
lieves that there are great individual differences, but that in some cases 
there is an increased metabolism of the resting cells. It is evident that 
the solution of this problem has important bearings upon the use of 
thyroid to influence metabolism; if the thyroid increases metabolism only 
indirectly by causing, through stimulation of the nervous system, increased 
activity, it could, for example, scarcely be considered a good treatment 
of obesity, at least in those forms in which thyroid deficiency is not a 
causal factor. 

Excessive doses of thyroid have marked effects upon the circulatory 
and nervous systems, but these are of interest chiefly in connection with 
the toxic action of the drug; they do not suggest any therapeutic use for 
it. Eppinger, Falta, and Rudinger attribute many of these effects to 
increased irritability of the sympathetic nervous system. Zondek and 
Frankfurter state that thyroid extract and iodothyrin cause broncho- 
constriction and dilatation of the lung capillaries. 

Thyroid Organotherapy in Other Conditions 

Thyroid has been given in many conditions that have not yet been 
definitely shown to be caused by thyroid deficiency. In some of these 
thyroid deficiency is merely suspected; in others thyroid is apparently 
used because the symptoms resemble some of those occurring in hypo¬ 
thyroidism. Among these conditions are various disturbances of the skin, 
especially the dry scaly varieties. Thus, it has been recommended in 
eczema, especially that of early childhood and of old age; it has been 
used in psoriasis, chronic urticaria, pemphigus, icythyosis, and sclero¬ 
derma. In the latter condition the thyroid has sometimes been found 
atrophied (Wells). 

Thyroid treatment has been tried in the toxemias of pregnancy on the 
theory that the intoxication is due to thyroid deficiency. This theory is 
highly improbable, as the syndrome of hypothyroidism does not at all 
resemble pregnancy toxemias. 

It has been used in various disturbances of the joints, such as arthritis 


THE THYROID 


669 


deformans, irregular gout, chronic rheumatism, and indefinite “rheuma¬ 
toid” pains. Among recent writers Levi and Rothschild have especially 
emphasized its value in certain forms of rheumatism of children; in 
these the thyroid is frequently enlarged (Clemens). It has also been 
used in cases of migraine and neuralgia, especially in those associated 
with menstruation. Thyroid has found extensive use in various disorders 
of menstruation. Experimental and clinical work has shown that the 
thyroid is necessary for the proper development of the gonads, the genital 
organs, and for menstruation. Further relations between the thyroid 
and the female sexual organs are suggested by the more frequent occur¬ 
rence of myxedema in women after the climacteric—especially in those 
who have borne children—the more frequent occurrence of exophthalmic 
goiter in women, and by the enlargement of the thyroid during menstrua¬ 
tion and pregnancy. It has been recommended in amenorrhea when other 
causes cannot be detected, and especially if there is a tendency to obesity 
or myxedema. Thyroid in large doses has been used in eclampsia. 

The influence of the administration of thyroid upon the defective 
growth of bone in cretinism suggested its use in delayed union of frac¬ 
tures ; some writers have reported favorable results. Bircher reports that 
the administration of thyroid to young animals delayed bone growth; this 
was probably due to excessive doses. He does not believe that the effect 
on bone growth in cretinism is specific. Thompson and Swarts, contrary 
to • some, did not find that removal of the thyroid delayed the healing 
of fractures. It has been said to have good results in rickets. Glosse 
proposes the theory that arthritis with accompanying disturbances of 
protein metabolism is due to lack of thyroid secretion, which he con¬ 
siders, under normal conditions, to act as a deamidizing agent. 

Good results have been reported from the use of thyroid in hemophilia. 
It is said that the preliminary administration of the drug renders neces¬ 
sary operations (extraction of a tooth, for example) safer. Such results 
must be doubted, for the coagulation of blood is said to be distinctly de¬ 
layed in Graves’ disease and experimental hyperthyroidism (and to be 
accelerated in conditions of hypothyroidism). Frazier and Peet have 
recently reported the cure of a case of internal hydrocephalus by thyroid 
administration. They were led to use this treatment by their laboratory 
findings that thyroid extract decreases the rate of formation of cerebro¬ 
spinal fluid. This observation is probably erroneous (Becht and Mattill). 

The marked mental changes produced by the administration of thyroid 
in myxedema and cretinism have led to the use of thyroid in various 
other types of insanity, mental disturbances, epilepsy, etc. The results in 
certain cases of beginning melancholic insanities are stated to have been 
good. It is interesting to note in this connection that a very large per¬ 
centage of patients with mental diseases has abnormal thyroids, and that 
Grafe has found in certain mental diseases a true retardation of metabo- 


670 


ORGAN OTHERAPEUTICS 


lism (heat production 39 per cent below normal, for example) which is 
suggestive of a condition of hypothyroidism. Ross administered thyroid 
to four dementia praecox patients and found an increased excretion of 
total nitrogen and of creatinin—this in evidence of hypothyroidism as a 
factor in this malady. 

Space does not permit, and in many cases the clinical reports are too 
incomplete, to evaluate the alleged favorable results of this purely em¬ 
pirical thyroid organotherapy, but the following comments seem war¬ 
ranted: (1) If there is in the patient sufficient hypothyroidism to induce 
amenorrhea, mental disorders, skin lesions, defective bone metabolism, 
lowered resistance to infection, etc., there must be other indubitable signs 
of thyroid deficiency, such as lowered basal metabolism. (2) Unless these 
conditions are due to hypothyroidism, administration of thyroid to these 
patients will, on the theory of Mobius, induce a state of hyperthyroidism, 
and there is no evidence that, this condition has a favorable influence on 
any malady. (3) There is no evidence that the augmented metabolism 
induced by thyroid administration is beneficial in any other condition than 
cretinism and myxedema. Moreover, a general increase in body metabo¬ 
lism can be induced by dietetic and hygienic measures, cold baths, exer¬ 
cises, etc. (4) When the failures are balanced against the favorable 
results in all cases of empirical thyroid organotherapy, there is little 
basis left for the belief that the thyroid treatment is really responsible 
for the latter. 


Methods of Administering Thyroid 

Transplantation. —The earliest attempts to combat deficiency were by 
the transplantation of normal thyroid. This method has succeeded when 
the thyroid is transplanted to another region of the same individual; it has 
been less successful when the gland is transplanted from one animal to 
another of the same species. It is, therefore, of experimental but of little 
or no practical clinical importance. It has been recommended in cases 
in which thyroid feeding does not produce notable improvement, as is 
usually the case in endemic cretinism (cretinic degeneration). Kocher 
states that one advantage of transplantation is that the body can regulate 
the amount of secretion according to its needs, but that is not true of a 
thyroid graft from another individual, even under the most favorable 
conditions (Manley and Marine). 

Subcutaneous Injections— Murray (1891) introduced the method of 
treating myxedema by the subcutaneous injection of glycerin extracts of 
thyroid; the extracts were obtained from sheep and calves, and were pro- 
served with phenol. They frequently caused severe local reactions. This 
method has no advantage over feeding the thyroid by mouth, but many 
disadvantages. It should never be resorted to. Thyroxin may be given 


THE THYROID 


671 


intravenously or hypodermically ; but this therapy has no advantage over 
thyroid extract feeding, and is at present very expensive for the patient. 

Administration by Mouth. —A very important advance in thyroid 
medication was made in 1892, when Fox, Mackenzie, and Howitz almost 
simultaneously announced that favorable results could be obtained in 
myxedema, by the administration, per os ., of the fresh or cooked thyroid. 
The use of cooked and fresh glands was soon practically replaced by the 
use of the dried glands, and of various extracts. Some of these have 
received recognition in various pharmacopeias. 

Official and Other Preparations of Thyroid 

Pharmacopeial Preparations. —Desiccated thyroid gland is recognized 
in the United States Pharmacopeia (VIII, 1905) under the name 
“Glandulse Thyroidise Siccse.” It is directed to be obtained from the 
sheep and to be freed of fat, and powdered; one part; represents approxi¬ 
mately five parts of the fresh glands. Tests are included to insure the 
presence of iodin in organic combination and the absence of inorganic 
iodin. The average dose is given as 0.25 gram, or four grains. 

Tablets. —At present thyroid is administered, at least in this country, 
chiefly as the dried powder which is usually prescribed in the form of 
tablets. Such tablets are very convenient and satisfactory if they are 
well chewed, but their use has led to the utmost confusion as to dosage. 
Many physicians both here and abroad speak of prescribing so many 
“tablets” without, as a rule, specifying either the size of the tablet or 
the maker; others speak of prescribing “two” or “five-grain tablets,” 
without specifying whether the weight refers to the total weight of the 
tablet (that is, the thyroid plus the excipient), or to the thyroid alone, 
and, in the latter case, as to whether the weight refers to the fresh or 
dried gland. Others specify some manufacturers’ “tablets” without fur¬ 
ther particulars. How inexcusably inexact such procedures are is evident 
from such facts as the following: Many manufacturers prepare several 
“tablets” of different sizes; one firm, for example, lists “one-half, one 
and one-half, two and one-half, and five-grain, and one-tenth, and three- 
tenths-gram tablets”; which of these tablets the patient received when 
the physician states that he administered this firm’s tablets it is usually 
impossible to determine. 

The confusion as to dosage is still further increased by the fact that 
different firms use different methods of expressing the amount of thyroid 
in their tablets. Thus, one firm’s “five-grain tablet” contains two grains 
of desiccated thyroid; another firm’s “five-grain tablet” means that each 
tablet contains the equivalent of five grains of the fresh gland. One 
firm’s “two-grain tablet” means that each tablet is equivalent to ten 
grains of the fresh thyroid; another firm states that one grain of their 


672 


ORGAN OTHER APEUTIOS 


dry thyroid represents eight grains of the fresh gland. There can he little 
doubt that, when some physicians write of prescribing a five-grain tablet 
of dry thyroid, they really prescribe a tablet containing the equivalent 
of five grains of fresh thyroid, or one-fifth of what the reader may be 
led to suppose. 

Since some “commercial” tablets contain twenty times as much 
thyroid as other “tablets” and since some preparations of thyroid are 
four times as active as others, there is a possibility of one “tablet” being 
equal, physiologically, to eighty other “tablets.” 3 

Extracts and Other Preparations.—In addition to the above, there are 
a number of extracts and other preparations of the thyroid on the market. 
The term “extract” is frequently applied to the dried powder, a practice 
often leading to confusion. 

Thyroidin-Merck. —Reference to this preparation is frequently made 
in the literature. It is dried thyroid, .4 gram of which is equivalent to 
one fresh sheep thyroid of medium size; one part represents about six 
parts of the fresh gland. 

ThyroidimN otkin. —This is a preparation of the proteins of the thy¬ 
roid, stated to he especially useful for hypodermatic injection. The dose 
per os is one-sixth of a grain; hypodermatically, 15 minims of a .5 per 
cent solution. 

Thyroxin (Kendall). —This is manufactured under Dr. Kendall’s 
direction by Squibb. It is a crystalline substance containing 65 per cent 
iodin. The dose is one or more milligrams, depending on the degree of 
hypo-function of the patient’s thyroid. Squibb also puts on the market a 
form of thyroxin not completely purified. 

Untoward Effects and Contra-indications.—Untoward effects not in¬ 
frequently follow the medicinal use of thyroid. There are, however, great 
individual differences in susceptibility. Children are stated to be less 
sensitive than adults; patients with myxedema as well as with toxic goiter 
are usually hypersensitive. This applies also to experimental cretins . 

Among the milder symptoms reported from overdoses, the long- 
continued use of smaller doses, or in especially sensitive individuals, are 
flushing with increased sweating, fullness of the head with palpitation of 
the heart, tachycardia and anginose pain in the heart, dyspnea, faintness, 
dizziness, loss of appetite, loss of body weight, etc. Such symptoms have 
followed the taking of two grains of the dry powder. Other symptoms 
are nausea, vomiting and severe diarrhea. Uoulis reported a case of 
profuse fatal diarrhea following the first dose of one-fourth of a lobe 
of thyroid in twenty-four hours. Glycosuria often occurs. Marked 

3 The above remark applies to the tablets on the American market. Equally 
great confusion prevails in regard to other “tablets” on foreign markets; thus 
in one case a .1-gram tablet contains one-fourth of a medium-sized thyroid of a 
sheep. 



THE THYROID 


673 


nervous disturbances may occur. In addition to the palpitation, etc., 
there may be great restlessness and sleeplessness, irritability, tremors, 
pains in the back and extremities, and even delirium. The temperature 
is sometimes elevated. Urticaria and other disturbances of the skin may 
occur. Great emaciation, long-continued debility, and anemia have been 
reported; the urine may be diminished, although, as a rule, thyroid has 
a diuretic action. As a rule these untoward effects subside within a few 
days after stopping the thyroid treatment, but Krecke reports that he 
has seen emaciation, tachycardia, and excitement continuing for a year 
after the administration of thyroid to patients with Graves’ disease. This 
was in all probability not due to the thyroid therapy. 

A large number of accidents, some of them fatal, have occurred from 
the use of thyroid in obesity. It is especially dangerous to obese patients 
with a tendency to cardiac or aortic disease. It is also contra-indicated 
in obese patients with a tendency to diabetes. 

Summary 

1. Thyroid organotherapy is definitely established in all conditions 
of hypothyroidism, that is, in all degrees of cretinism and myxedema. 
The administration of the entire gland substance (dried) by mouth in 
doses that must be determined for each individual 'patient is the best 
method of procedure. This therapy must ordinarily be continued indefi¬ 
nitely. We should insist on chemical and physiological standardization 
of the thyroid products. 

2. Because of the present uncertainty as to the cause and signifi¬ 
cance of the thyroid hyperplasia in toxic goiter, and the not infrequent 
occurrence of toxic goiter and myxedema in the same patient at the same 
time, thyroid administration may be tried experimentally in these con¬ 
ditions, especially in the very early and in the later stages. But Howard 
believes this use of thyroid extract should be discouraged. 

3. If we assume, with Mobius, that an excess of thyroid secretion 
in the blood produces the untoward symptoms of toxic goiter, it follows 
that an increase of thyroid secretion above the normal is injurious. Hence, 
on this generally accepted theory, it is evident that thyroid administra¬ 
tion is contra-indicated in all conditions not due to thyroid deficiency, 
for, by giving thyroid in such cases, we probably increase its concentration 
above the normal in the body fluids and the tissues. The results obtained 
by thyroid organotherapy in various diseases other than hypothyroidism 
do not appear to justify further clinical empiricism in that direction until 
well-controlled laboratory tests have established new lines of attack. 

4. The various theories ascribing to the thyroids specific inhibitory 
or stimulating functions on other endocrine organs, other than through 
the general body metabolism, have so little basis in fact that there is no 


674 


ORGANOTHERAPEUTICS 


justification for thyroid administration in cases of supposed hyperactivity 
or hypo-activity of such organs, or in supposed general disturbance of 
internal secretion equilibrium. 


THE PARATHYROIDS 

Physiology.—The parathyroids, like the thyroid gland, develop from 
the epithelium of the embryonic gill arches. In man and most mammals 
the parathyroids are either imbedded in the thyroid gland, or lie close to 
the thyroid capsule. There are usually two pairs of parathyroid glands 
in man and mammals in general, but accessory parathyroids are fre¬ 
quently present in the thymus, and associated with accessory nodules of 
thyroid tissue both in the neck and the chest. The glands were discovered 
by Sandstrom in 1880, but their specific role was not recognized by 
physiologists and clinicians until a much later date. Because of the 
situation of the parathyroids in or on the thyroid gland, complete thy¬ 
roidectomy involves, in most mammals, also complete parathyroidectomy, 
and the characteristic syndrome developing as a result of parathyroid 
extirpation as for many years erroneously ascribed to deficiency of the 
thyroids. 

The striking thing is the relatively small amount of total parathyroid 
tissue in animals, and the serious effect that develops promptly on the 
extirpation of the glands, at least in many species. Histologically the 
parathyroids are made up of columns of epithelial cells, without the acini 
or colloid so characteristic of the thyroid gland. Vincent and his pupils 
have reported that on extirpation of the thyroids the parathyroids develop 
into typical thyroid structure. Vincent has adduced other evidence in 
support of his theory that the parathyroid glands represent an embryonic 
state of the thyroid. But Vincent’s experimental results have not been 
substantiated by other investigators. It is certain that in the rabbit com¬ 
plete thyroidectomy does not cause the parathyroids to assume the struc¬ 
ture and function of the thyroid (Basinger). The functional independ¬ 
ence of the thyroid and the parathyroids is further shown by the absence 
of iodin in the parathyroid gland. The earlier workers who reported 
iodin in the parathyroids were not careful to exclude traces of thyroid 
tissue. This is practically impossible, if one uses the parathyroids that 
are embedded in the body of the thyroid gland. 

While it is generally assumed that the parathyroids produce an in¬ 
ternal secretion, this theory rests on a very slight foundation of facts. 
It is a fact that complete extirpation of the glands leads quickly to the 
development of grave or fatal symptoms, but we do not know how the 
living parathyroids prevent the toxemia of tetany. 


THE PARATHYROIDS 


675 


Extirpation of the Parathyroid. —Practically all that is known of the 
functions of the parathyroids has been learned from the extirpation of 
these glands in animals and man. The typical symptoms in animals are 
as follows: There is a latent period of several (twelve to forty-eight) 
hours in which the only symptoms may be a loss of appetite, some in¬ 
creased thirst, and a condition of hyperirritability of peripheral nerves. 
Then appear general unrest and fibrillary contractions of various muscles, 
especially of the tongue and jaws; these become more frequent and are 
accompanied by a stiffness of the extremities and clonic contractions of 
groups of muscles. The clonic contractions then extend to all the muscles, 
leading to the typical tetanic attacks, which are accompanied by salivation 
and increased cardiac and respiratory activity, and, in most animals, a 
rise in temperature. These attacks are succeeded by a condition of pros¬ 
tration, during which the dyspneic respiration gradually returns to nor¬ 
mal. The animals may apparently completely recover, but, within a few 
hours or a day or two, new attacks develop and death occurs. In dogs the 
duration of life after complete removal of the parathyroids rarely exceeds 
ten to fourteen days. 

If only two or three parathyroids are removed, there may develop 
a condition of latent tetany; in this case there are often no symptoms 
except under special conditions. Among the influences provoking attacks 
of tetany in such animals are the occurrence of rut, pregnancy, lactation, 
violent nervous and muscular exertion, constipation, high protein diet. 
The administration of various poisons (phosphorus, amines, etc.) may 
also provoke an attack. 

The rate of development and the final degree of the increased ex¬ 
citability of the motor neurons following parathyroidectomy in the dog 
are not appreciably influenced by ablation of the cerebral motor cortex, 
spinal transection, or section of the dorsal nerve roots. The increased 
excitability is therefore probably due primarily to some direct chemical 
action on the motor neurons. 

The course of the parathyroid tetany is not appreciably influenced 
by ablation of the motor cerebral cortex, or by rendering a limb atonic 
through section of its afferent nerves. 

As the epileptic spasms or tetanic attacks following removal of the 
parathyroid glands do not develop posterior to the spinal transection, it 
would seem that the actual tetany depends, not only on the local increase 
of motor excitability in the spinal cords, but also upon nervous connec¬ 
tions with some region of the encephalon below the cerebral cortex 
(Mustard): 

Wilcox found that removal of one to two or three of the parathyroids 
in dogs may induce more or less permanent hyperexcitability of the 
nerves, but no tremors or tetany, even during pregnancy or lactation. 
But it is significant that the nervous hyperexcitability becomes more 


676 


ORGANOTIIERAPEUTICS 


marked during pregnancy, and especially during lactation. When all 
the parathyroid tissue is removed in the dogs the hyperexcitability of 
the peripheral nerves is in evidence one to three days before the appear¬ 
ance of tremors and tetany. 

In some cases of parathyroidectomy, cachexia and depression appear 
at the very onset without any evident period of nervous hyperexcitability. 
This is particularly frequent in cats. The cachexia and depression is 
usually accompanied by subnormal temperature. Practically all animals 
that survive the violent attacks of tetany and pyrexia die in cachexia 
and depression. 

Extirpation of the parathyroid causes, on the whole, a more violent 
and rapidly fatal tetany in the carnivora than in herbivora, and in the 
latter group the adult animals are frequently less affected by loss of the 
parathyroids than the young animals. 

Parathyroid Tetany and the Digestive Tract. —Parathyroid tetany in 
dogs is accompanied by gastro-intestinal disorders; anorexia, vomiting, 
diarrhea (usually), pain in the abdominal region, and in the majority of 
cases hyperemia, hemorrhages and ulcers of pyloric and duodenal mucosa. 
The hyperexcitability of the peripheral nerves in dogs in parathyroid 
tetany is usually, but not always, shown by stimulation of the phrenic 
nerves by the action current of the heart. 

Falta and Kahn describe cases of tetanic contraction of the stomach 
in human tetany. There are no spasms, contractures or other evidences 
of hyperexcitability or tetany of the neuromuscular mechanisms of the 
digestive tract in parathyroid tetany in cats and dogs. Even in very 
severe tetany the movements of the stomach and intestines may be normal; 
the deviation from normal is in the direction of depression or paralysis. 
The gastric and pancreatic digestion in tetany may be normal, but it is 
usually retarded. The retardation may amount to practical failure of 
digestion. In very exceptional instances there may be acceleration of 
the gastric motility (cats). The retarded digestion is not due to the 
absence of appetite secretion or to splanchnic inhibition; it is probably due 
either to direct action of substances in the blood on the digestive glands 
(secondary effects), or to altered activity as a direct effect of the absence 
of the parathyroid secretion. In the case of other sympathetic and auto¬ 
matic mechanisms (cervical sympathetic, pilomotors, sweat nerves, the 
uterus, the bladder, the sphincters), the deviation from normal activity 
in parathyroid tetany in cats and dogs seems also to be in the direction 
of depression. 

In cats and dogs Keeton found a diminished secretion of gastric 
juice during parathyroid tetany, and the juice contains less than the 
normal amount of pepsin and hydrochloric acid. The impairment of 
the gastric secretion is, on the whole, directly proportional to the 
severity of the tetany. Stoland found that the quantity of the pan- 


THE PARATHYROIDS 677 

creatic juice and the bile secreted is also greatly diminished in 
tetany. 

The hunger contractions of the empty stomach in parathyroidectom- 
ized dogs are depressed in direct proportion to the severity of the tetany. 
In extreme tetany the empty stomach is atonic and dilated. This is prob¬ 
ably a factor in the characteristic anorexia of tetany animals. 

The condition of the digestive tract in experimental parathyroid tetany 
is of great interest, in view of the various types of tetany of gastro¬ 
intestinal origin in man. While it has been known for a long time that 
feeding meat to parathyroidectomized animals hastens and intensifies the 
tetany symptoms, and that starvation retards and diminishes the tetany 
symptoms, it is nevertheless probable that the gastro-intestinal symptoms 
of parathyroid tetany in animals are mainly the effects of the tetany 
toxemia and not the primary cause of the tetany syndrome. 

Parathyroid Tetany and the Liver. —The injurious effects of protein 
food and the amines, etc., various changes in the blood and in the urine, 
glucosuria, acidosis, increase of ammonia and amino-acids in the urine, 
reported by a number of observers in tetany animals have naturally 
directed attention to the liver. Carlson and Jacobson called attention 
to the marked similarity of parathyroid tetany, the tetany of ammonia 
intoxication, and the nervous hyperexcitability produced by meat feeding 
in dogs with the blood shunted past the liver into the general circulation 
by the Eck fistula. There is some histological evidence of liver degenera¬ 
tion in animals dying in tetany; and in the clinical tetany of pregnancy 
(eclampsia) there appear also to be instances of liver involvement. But 
extensive investigations on tetany dogs have failed to disclose any pri¬ 
mary liver depression of importance except a diminished secretion of bile, 
and this is probably due to the condition of the digestive tract rather than 
to the absence of specific parathyroid secretion. But Dragstedt has re¬ 
cently shown that parathyroidectomized dogs in which the appearance 
of tetany is prevented by suitable diets, phosphorus or guanidin adminis¬ 
tration in quantities having little or no effect in normal animals, causes 
violent tetany. 

During parathyroid tetany there is no change in the sugar tolerance 
(Stoland, Miura) ; the excretion of ammonia and amino-acids in the 
urine is normal, or less than normal in early tetany (Wilson, Steams 
and Janney) ; the blood fibrinogen is normal or greater than normal. The 
formation of fibrinogen is one of the functions of the liver, hence the 
use of the blood fibrinogen as a test of liver function. But inasmuch as 
the secretion of bile is decreased, a functional liver test depending on 
excretion of pigments in the bile would probably disclose, erroneously, 
a liver depression in tetany animals. Of course, it is obvious that, when 
the tetany condition has rendered the animal moribund, the liver will 
be depressed along with the entire organism, d his is of no significance. 


678 


OKGANOTHERAPEUTICS 


The question of importance is whether there is any evidence of liver de¬ 
pression that can account for the genesis of the tetany itself. Such liver 
changes have not yet been demonstrated. 

The Blood in Parathyroid Tetany.—The literature on this most im¬ 
portant phase of parathyroid physiology and pathology is conflicting. 
MacCallum and Voegtlin reported a marked acidosis, with a decrease of 
the calcium salts of the tissues and the blood and an increased excretion 
of calcium in the urine. None of these results has been confirmed 
(Cooke). But Marriott and Howland report a decreased calcium content 
in the blood of spasrpophilic children. Berkheim, Stewart and Hawk 
report a case of probably complete parathyroidectomy in a man, with 
slight retention of calcium salts. In later experiments MacCallum re¬ 
ported that transfusion of the blood of tetany dogs through the leg of a 
normal dog raised the excitability of the motor nerves of the transfused 
leg of a tetany dog, while transfusion of normal blood through the leg of a 
tetany dog reduced the excitability of the nerves of the tetany leg. It does 
not appear that Dr. MacCallum controlled the temperature factor of the 
transfused blood. Fever blood will, of course, raise the excitability of the 
nerves, by the temperature factor alone. Yoshimoto reports that the blood 
of dogs in tetany, as well as solutions of guanidin, increases the irritability 
of the sciatic nerve of the frog. 

In connection with the theory of calcium deficiency on the course of 
tetany, it is interesting to note that Thompson, Leighton and Swartz, and 
Morel have reported that traumatism of bone prevents tetany from re¬ 
moval of the parathyroids ; it does not, however, prevent the development 
of cachexia. 

Peterson, Jobling and Eggstein report a diminution of the serum 
lipase, a gradual increase in the non-coagulable nitrogen and proteoses of 
the blood and an increase in the aminonitrogen at the height of the tetany. 
Cooke and Greenwald report an increase in the undetermined urine 
nitrogen. According to Greenwald there is a marked retention of phos¬ 
phorus after parathyroidectomy, and this is accompanied by retention of 
sodium and potassium. But in the quantities present the sodium or po¬ 
tassium phosphates are probably not sufficiently toxic to be the agent of 
the tetany. 

Greenwald also showed that xanthin and inosinic acid are not the 
toxic agents, for there is not enough of either of these substances in the 
blood or tissue of tetany animals to cause symptoms, although intravenous 
injections of large amounts of xanthin cause convulsions. The signifi¬ 
cance of the phosphorus retention in parathyroid tetany is as yet un¬ 
explained; but the work of Erdheim and others indicates that chronic 
parathyroid deficiency leads to impairment of bone growth. 

Koch and Paton, Findlay and Burns report that there is an increase 
in the excretion of methyl cyanids, and trimethylamin, or guanidin in 


THE PARATHYROIDS 


679 


the urine of tetany dogs. Injection of these subtances into animals induces 
symptoms similar to parathyroid tetany. But there is no evidence that 
there is sufficient concentration of guanidin in the blood to induce the 
tetany in parathyroidectomized dogs. Using biological tests, several ob¬ 
servers have reported an increased toxicity of the urine of tetany animals. 

Wilson, Stearns and Janney find that after parathyroidectomy there 
is a primary alkalosis, or greatly increased alkalinity of the blood, and 
that acidosis is a secondary effect of the severe tetany owing to the for¬ 
mation of acids as a result of the muscular contraction. These observers 
advance the theory that the alkalosis is the primary factor in the tetany, 
and support this view by the fact that giving of alkalis increases the 
tetany, while administration of acids decreases the tetany. The reader 
will recall that MacCallum found similar support for his theory of pri¬ 
mary calcium deficiency in the fact that calcium injections decrease 
the tetany symptoms temporarily. Acids, as well as calcium salts, depress 
the nervous tissues, but this drug action does not prove the primary rela¬ 
tion of alkali excess or calcium deficiency to the genesis of parathyroid 
tetany. 

Several investigators (Grant and Goodman, etc.) have recently re¬ 
ported the production of a temporary tetany in man and animals by 
excessive lung ventilation (forced breathing), thus reducing the carbon 
dioxid of the blood, and presumably increasing the alkalis. But these 
findings do not explain parathyroid tetany. According to Greenwald 
the tetany following forced respiration is due to the excess sodium ions 
in the blood. Uhlenhuth has reported tetany toxins in the thymus (feed¬ 
ing thymus to tadpoles). 

Temporary Control of Experimental Parathyroid Tetany.—Some of 
the earliest investigators of the physiology of the parathyroids (Lusena, 
Vassale, Generali, Moussu, MacCallum) reported that the tetany could 
be checked by the injection (subcutaneous, intraperitoneal, or intravenous) 
of emulsions of the parathyroids; favorable results were also reported 
from the feeding of the gland. Berkeley and Beebe report that the active 
part of the gland is the nucleoprotein fraction; this was said to be efficient 
when given by the mouth, but much more so when given subcutaneously. 

The treatment of parathyroid tetany, by the administration of the 
parathyroid glands, differs in important particulars from that of myx¬ 
edema by the administration of thyroid. The effect of thyroid is strictly 
specific; no other gland substance will relieve the symptoms. It has been 
found, on the other hand, that parathyroid tetany can be temporarily 
checked, at least in the early stages, by the administration of salts of 
calcium, magnesium, strontium, and barium; by the injection of large 
amounts of sodium chlorid solution; by the injection of acids; by injection 
of extracts of the thyroid, the thymus, the pancreas, the testes, and the 
hypophysis; by the injection of proteoses or peptones; by the injection 


C 80 


ORGAHOTHERAPEUTICS 


of hypertonic sugar solutions; by the administration of amyl nitrate, etc. 
In dogs the early attacks of parathyroid tetany can usually he decreased 
or prevented by giving the animal a cold bath, reducing the pyrexia. 
Transfusion of normal blood into parathyroid tetany dogs decreases the 
tetany but little, and does not lengthen the life of the animal. 

Administration by Mouth.—Giving parathyroids by mouth appears 
to be entirely useless in the hands of later investigators (MacCallum and 
Voegtlin, Marine). Marine gave as many as one hundred fresh para¬ 
thyroids per day to dogs with complete tetany, without amelioration of 
the symptoms or prolongation of life, but transplantation of even a single 
parathyroid from another species controlled the tetany for a few days, or 
until the gland was completely absorbed. 

All these measures have so far proved to be only temporary palliatives. 
Their action is complicated by the spontaneous periodicity of the symptoms 
in the early stages of the disease, and by the complete and spontaneous 
recovery in some individuals. The efficiency of these measures varies 
indirectly with the stage of the cachexia and the severity of the excitation 
symptoms. The action of all these therapeutic measures can probably be 
accounted for by decreased excitability of the nervous tissues. The ex¬ 
citability is decreased directly by the drug action of the calcium and the 
strontium salts and by hypertonicity; indirectly by substances or measures 
that cause partial anemia of the brain through vasodilatation (tissue 
extracts, albumoses, amyl nitrite, stimulation of the depressor nerves). 
Hone of these measures has therefore any specific significance as regards 
the cause and nature of parathyroid tetany. 

In most of the experiments the administration of the above substances 
has relieved the symptoms of tetany only, the animals dying later in 
cachexia. The cases of complete recovery are probably due to hyper¬ 
trophy of accessory glands, or to gradually acquired tolerance to the 
tetany toxins. Thus, valuable as the administration of the gland or in¬ 
jections of salts of calcium may be in checking the symptoms of tetany 
and in prolonging life, it is open to question whether it is possible to 
restore normal conditions in complete parathyroidectomy, except by suc¬ 
cessful implantation of a living gland. 

Transplantation of Glands.—For the complete relief of parathyroid 
insufficiency transplantation of the glands is the only effective measure, 
but the results have been disappointing (Halsted, Leischner and Kohler, 
Landois, Marine, and others). Halsted concludes that transplantation 
succeeds only when a parathyroid deficiency has been previously induced, 
and that parathyroid tissue transplanted in excess of what is urgently 
required by the organism does not live. 

Permanent Control of Parathyroid Tetany in Dogs.—It has been 
found that parathyroid tetany in dogs can be permanently controlled by 
diet, diuresis, and feeding of calcium lactate. 


THE PARATHYROIDS 


681 


Dragstedt lias shown that parathyroidectomy in dogs on a diet of milk, 
lactose and bread or dextrin does not lead to tetany or death, and if this 
diet is kept up from four to six weeks the ordinary meat diet (in modera¬ 
tion) may be restored without inducing tetany. The above diet changes 
the intestinal flora in dogs from the normal putrefactive to an aciduric 
type. This diet is not invariably successful in preventing tetany and 
maintaining life after parathyroidectomy in pregnant bitches. This indi¬ 
cates that the fetus (and possibly the placenta) is a source of tetany 
toxins. These clear-cut experiments on non-pregnant dogs seem to show 
that: 

1. The tetany is due to exogenous toxins and these toxins are de¬ 
veloped by the intestinal proteolytic flora acting mainly on the food 
proteins (meat). 

2. The parathyroids in dogs are not necessary for life. After the 
initial dietary control of the acute symptoms, the dog seems quite normal, 
even on a meat diet. This may be due to an increased tolerance to the 
tetany toxins, or an increased destruction of these toxins by other organs 
in the body. 

3. The dogs are not normal. They are in the condition of latent 
tetany or epilepsy, so that constipation, excessive ingestion of meat, rut, 
pregnancy, poisons, or excitement induce tetany attacks of varying 
severity. 

Luckhardt has shown that parathyroidectomized dogs (pregnant as 
well as non-pregnant) on a high meat diet can be kept free from tetany 
(1) by a daily feeding of large quantities of calcium lactate (about 
1.5 gr. per kilo body weight) for from four to five weeks, after the opera¬ 
tion; and (2) by maintaining a brisk diuresis for a corresponding period 
by means of intravenous injections of large quantities of Ringer’s solu¬ 
tion, or salt solution. After four or five weeks, both the calcium and the 
diuresis therapy can be dispensed with, the animals live indefinitely and 
show no tetany, except under the same conditions as stated in Dragstedt’s 
experiments. All of Luckhardt's 'parathyroidectomized dogs that have 
lived for a year or more have developed cataract. 

Luckhardt’s diuresis experiments can be most readily explained on 
the basis of rapid elimination of the tetany toxins by the kidneys. The 
life-saving action of calcium lactate when given by mouth is less readily 
understood. Calcium lactate intravenously will not save a parathyrec- 
tomized dog from death; in fact, given in this way, the salt produces 
nephritis. The huge doses of the salt necessary per os is a further indi¬ 
cation that the mechanism is not that of making up a calcium deficiency 
in the tissues. The calcium may act in. the gut by modifying the action 
of the intestinal bacteria, or fixing bacterial toxins. 


ORGANOTHERAPEUTICS 


682 


The work of these two investigators has greatly advanced our analysis 
of parathyroid function and parathyroid tetany. It has given us an ade¬ 
quate and practical therapy of this tetany. It suggests new lines of 
therapy of tetany and allied disorders in man. But it does not tell 
us how the intact and normal parathyroids prevent tetany, whether by 
direct neutralization of the toxins, or by furnishing a hormone that regu¬ 
lates the permeability of the intestinal mucosa, or stimulates 1 various 
organs to increased detoxication. 

Parathyroid Deficiency in Man.—The clearest cases of parathyroid 
insufficiency in man are those in which the glands have been more or 
less completely removed or injured at operation on the thyroid. Cases 
of this character are not uncommon, especially from interference with the 
circulation of the glands. The symptoms of postoperative tetany in man 
are very similar to those described in animals. If death does not occur 
in a short time, a chronic condition of latent tetany or of subtetanic hypo- 
par athyreosis (Halsted) develops. Such a condition may continue for 
years with chronic nervous hyperexcitability (Erb, Chvostok and Trous¬ 
seau signs), the patient having attacks of tetany at irregular intervals. 

Another form of tetany, in which a condition of parathyroid insuffi¬ 
ciency may exist, is that which occurs in pregnancy or lactation. At 
other times there may be no evidence of tetany. This form is strikingly 
like that observed in parathyroidectomized animals; it has also been 
observed in women after operation on the thyroid (Frank). Krabbel 
reports the case of a girl who for seven years had tetany only during 
menstruation; she was completely relieved by the implantation of para¬ 
thyroids into the tibia. Cases are also reported in which coitus induced 
tetanic convulsions. 

Another form of tetany, the etiology of which is still obscure, is that 
of children. A number of writers have reported finding extensive hemor¬ 
rhages into the parathyroid glands in this condition. Others, however, 
state that such hemorrhages are comparatively common in infants, and 
maintain that they are found as frequently in children who do not show 
tetany symptoms during life as in those who do (Auerbach). Extensive 
hemorrhages into the parathyroids have been reported in cases of sudden 
death, with spasms, of children (Grosser and Betke). Haskins and Ger- 
stenberger found no evidence of parathyroid involvement in infantile 
tetany. 

Attempts have been made to bring tetany of gastro-intestinal origin, 
toxic tetany, and those forms associated with various nervous diseases, 
into relation with the parathyroids. Parathyroid deficiency has been 
suspected as a factor in paralysis, agitans, myotonia congenita, myoclonia, 
chorea, osteomalacia, rickets, eclampsia, and idiopathic epilepsy, but 
nothing conclusive has as yet been demonstrated. Greenwald’s studies 
on the blood of paralysis agitans do not support the theory of parathyroid 


THE PARATHYROIDS 


683 


genesis of this disease. According to Cornby, some types of idiocy are 
due to parathyroid deficiency. 

Spontaneous atrophy or hypertrophy of the parathyroids in man have 
not been definitely established, but they probably occur, especially with 
age. Gjestland reports hyperplasia of the parathyroids in Parkinson’s 
disease. Roussy and Clunet report parathyroid hyperplasia in paralysis 
agitans. Bergstrand and others have reported parathyroid hyperplasia 
in chronic nephritis. 

Parathyroid Organotherapy.—Efforts to control the tetany, following 
the removal of the parathyroids or the effects of interference with their 
blood supply by the administration of parathyroids, have met with no 
certain success. Halsted states that in a patient suffering from subtetanic 
hypoparathyroidism as the result of two operations upon a large goiter, 
tetany had for three years been averted and the status parathyreoprivus 
made endurable by the feeding of parathyroids, by hypodermic injections 
of the nucleoproteins of the parathyroid gland, and for almost one year 
by the administration of calcium lactate. At the beginning six dried 
beefs’ parathyroids were given every three hours; the effect was “almost 
instantaneous and most marvelous.” The dose was then reduced to 
one gland three times daily; further reductions could not, for several 
weeks, be borne. Later fresh glands were substituted; these were more 
readily taken than the dried ones. 

Branham used subcutaneous injections of emulsions of beef para¬ 
thyroid with success in a case following operation for goiter; the tetany 
disappeared permanently after a second injection. It is evident that this 
patient would have recovered without the parathyroid treatment. 

Schneider reported a case of postoperative tetany in which the ad¬ 
ministration of the dry parathyroid of the horse (0.02 gram in two days) 
was followed by improvement ; the symptoms later reappeared, but dis¬ 
appeared after 0.03 gram of parathyroid. Other favorable reports have 
been published by Bircher, Rossiysky, and others. Eschrich, Erankel- 
Hochwart, Pineles, Rensburg, and others report negative results from 
parathyroid therapy in human parathyroid tetany. 

Several cases have been reported in which relief or cure of post¬ 
operative tetany followed transplantation of the gland. Leisehner and 
Kohler obtained only temporary relief from transplantation in one case, 
and no results in another. They suggest that in some of the apparently 
successful cases in transplantation in man there was a regeneration or 
recovery of function by the remnants of parathyroid tissue of the patient. 

Parathyroid has been administered with inconclusive results in a 
number of other forms of tetany and in other conditions ; the influence 
of suggestion has not always been eliminated. Haskins and Gersten- 
berger obtained no effects from parathyroid and calcium administration 
in one case of infantile tetany. 


684 


ORGANOTHERAPEUTICS 


Berkeley relieved the symptoms of gastric tetany by the administra¬ 
tion, by month, of fresh beef parathyroids; Moffitt also reports favorable 
results from the use of the dried powder, and later from hypodermic 
injections of the nucleoproteid of beef parathyroids. 

Loewenthal and Wiebrecht obtained good results from parathyroid 
feeding in infantile tetany; but others have reported entirely negative 
results. 

Berkeley reports better results from the administration of parathyroid 
in paralysis agitans than from any other remedy. Of twenty-six cases 
treated, five were not benefited, three showed temporary improvement, and 
eighteen grew progressively better during the whole period of treatment. 
Roussy and Clunet observed slight temporary improvement in two cases, 
a distinctly bad effect in two others, and no effect in a fifth case. They 
report a condition of parathyroid hyperplasia (whether primary or sec¬ 
ondary not determined) in this disease. Oppenheim recommends the 
administration of doses corresponding to 0.06 gram of the fresh gland 
several times a day. 

Favorable results have been reported from the use of parathyroid in 
eclampsia, epilepsy, idiocy, and chorea—especially in adults (Garavini). 
It will be recalled that several clinicians have reported favorable effects 
from the use of thyroid extract in eclampsia, on the theory that this type 
of tetany is due to thyroid deficiency (Nicholson, Sturmer). 

Morris reports injurious effects following prolonged administration 
of parathyroid gland by mouth. In a patient with paralysis agitans the 
feeding produced disturbing mental symptoms and insomnia, but no • 
improvement of the paralysis agitans. 

Summary 

1. Parathyroid deficiency in man and experimental animals leads 
to chronic nervous hyperexcitability, occasional tetany, and some cachexia. 
Total loss of the parathyroids leads to death in from two to fifteen days 
in tetany or extreme cachexia, especially in carnivorous animals. The 
primary disturbance following parathyroid ablation appears to be due 
to a toxemia, primarily of the intestinal (putrefaction) origin, and 
accumulation of toxic protein derivatives in the blood. 

2. All therapeutic measures that temporarily reduce the excitability 
of the nervous system will diminish or prevent parathyroid tetany tem¬ 
porarily, but they cannot save the life of the patient or the experimental 
animal in total absence of the parathyroids. The tetany is controlled and 
life prolonged indefinitely by diets that render the intestinal flora aciduric, 
by marked diuresis, and by feeding large quantities of calcium lactate, 
but these surviving animals are in a state of latent tetany. 

3. No definite causal relation between parathyroid deficiency and 





THE PANCREAS 


685 


eclampsia, infantile tetany, gastrointestinal tetany, paralysis agitans, 
idiopathic epilepsy, etc., has been so far established. The reports on 
parathyroid organotherapy in these maladies are so conflicting and un¬ 
satisfactory that no reliance can be placed on the few favorable results 
recorded. Parathyroid organotherapy in these conditions is at present 
purely experimental and empirical. 

4. The results to date on man and experimental animals indicate 
that true parathyroid tetany cannot be controlled, even temporarily, by 
giving parathyroid gland by mouth, or by transfusion of normal blood. 
The hypodermic or intramuscular administration of parathyroid extracts 
is of doubtful value, even as a temporary measure, and animal experiments 
show conclusively that such administration fails to prevent death in 
tetany or cachexia in the total absence of parathyroid. In light of our 
present experimental and clinical experience, parathyroid transplantation 
is the most promising therapy in all types of parathyroid deficiency, 
while diet, diuresis and lime salts per os merely control the conditions. 
The extremely conflicting results of parathyroid organotherapy, both in 
man and animals, are probably due to the frequency of accessory para¬ 
thyroids, so that alleged complete parathyroidectomy is, in many cases, 
only partial parathyroidectomy with temporary nervous hyperexcitability 
and tetany symptoms. According to the researches of Halsted and others, 
such parathyroid remnants will undergo hypertrophy and may finally meet 
the entire need of the organism, in which case the animal or the patient 
recovers permanently. Any therapy of such temporary tetany conditions 
will be successful, by post hoc reasoning, although it has nothing to do 
with the recovery of the animal or the patient, except such measures as 
may temporarily check the hyperexcitability of the nervous tissue. 

5. With the modern care in thyroid surgery, cases of definite para* 
thyroid deficiency in man become less frequent. Parathyroid organ¬ 
otherapy of other types of clinical tetany will contribute little or nothing 
to medical progress, until further advances have been made in the physi- 
ology, pathology and chemistry of the parathyroid glands. But the 
dietary, diuretic and calcium lactate therapies of Dragstedt and Luck- 
hardt may prove beneficial in these disorders. 


THE PANCREAS 

In 1889, von Mering and Minkowski discovered that complete extir¬ 
pation of the pancreas in the dog produces fatal diabetes. This has been 
abundantly confirmed on all species of vertebrates so far investigated. 
The attempts of Pfluger and others to show that the diabetes following 
removal of the pancreas is due, not to the absence of the pancreas, but to 



686 OEGANOTHERAPEUTICS 

injury to the duodenum and the nerves connecting the pancreas with the 
rest of the viscera, must be considered a failure. The original conclusion 
of von Mering and Minkowski is definitely established: The complete 
or nearly complete loss of the pancreas results in fatal diabetes. The 
more recent investigations of the condition of the pancreas, in clinical 
diabetes (Opie, Allen and others) have shown that in severe diabetes 
or in deaths in diabetes there is usually more or less degeneration of the 
pancreas, especially in the island tissue. The conclusion that the pan- 


Fig. 5. —Microphotograph (X 38) of a Portion of the Pancreas of the Guinea 
Pig Stained Intra Vitam by Neutral Red. This shows the normal variations of 
the size and frequency of the islands of Langerhans—dark areas. (Bensley.) 

creas is absolutely essential to life and to carbohydrate metabolism is thus 
based on experimental and clinical data, and established beyond a doubt. 

The part of the pancreas concerned in this function appears to be 
essentially the islands of Langerhans. This seems to be demonstrated 
by the following facts: 

1. Loss of the external pancreatic secretion (by permanent fistula of 
the pancreatic ducts) does not induce diabetes. 

2. Ligation of all the pancreatic ducts leads ultimately to complete 



THE PANCREAS 


687 


degeneration of all the pancreas tissue, except the islands of Langerhans 
—at least in animals like the rabbit and guinea pig. Such animals with 
only islet tissue left do not develop diabetes unless these remnants of the 
pancreas are extirpated. 

3. In clinical diabetes the pancreatic lesions usually involve the islets. 
Despite these facts the view that the entire pancreas tissue is concerned 
in the maintenance of the capacity of the tissues to oxidize the carbohy¬ 
drates is still maintained by some clinicians and biologists. This view 
finds its strongest support in the fact that human diabetes may reach 
a fatal issue while there still remains an abundance of apparently normal 
island tissue in the pancreas, as determined histologically. It is possible, 
however, that normal function is reduced or lost before anatomical or 
chemical degeneration of the cells reach such magnitude that they can 
he detected by the microscope. This theory of identity of function of the 
entire pancreas was also supported by the work of Dale, Vincent and 
Thomson, and others, which appeared to show that the islets represented 
only stages of fatigue or rest of the ordinary pancreas tissue. Laguesse, 
Bensley, and others have shown that this is untenable. While the islets 
and the acini develop from the same embryological anlage (the cells of 
the ducts), when finally differentiated they show constant and specific 
structural and chemical characteristics, evidently indicating specificity of 
function; and there is no foundation for the view that the one tissue 
is or can be transformed into the other. 

The Islands of Langerhans.—The number and size of the islets vary 
greatly in different species, as well as in individuals of the same species. 
In some fishes they are macroscopic, and separated from the rest of the 
pancreas. In man the islets have been estimated to make up one twenty- 
fifth to one one-hundredth part of the entire pancreas tissue, or a total of 
2.3 grams. In a normal animal five-sixths of the total pancreas can be 
removed without inducing diabetes, so that the “factor of safety” is very 
great. The total number of islands in mammals appears to be fixed at, 
or rather, before birth (Bensley). 

Lane and Bensley have shown that the island tissue is made up of 
two distinct types of cells, showing specific staining reactions, a less 
abundant alpha type, and a more numerous beta type. According to 
Homans it is the beta cells that show degeneration changes in clinical 
diabetes. 

The islets develop from the undifferentiated duct cells and may or 
may not retain this original connection with the ducts, but in either case 
the blood supply of the islets is greater than to the rest of the pancreas 
tissue. In this respect the islets resemble the adrenals and the thyroids. 
In fact, blood sinuses similar to those of the adrenals have been described 
in the islets (DeWitt). 


688 


ORGANOTHERAPEUTICS 


The islets are also abundantly supplied with nerve fibers (Gentes, 
Pensa, Laguesse). Groups of ganglion cells are also distributed in the 
body of the pancreas. The function of the nerves distributed to the 
islets is unknown. Some of them are undoubtedly vasomotor nerves, but 
others form a network between or around the islet cells, which appears 
to indicate a secretory or reflex function. 

Experimental Pancreatic Diabetes.—Extirpation of the whole or 
more than six-sevenths of the pancreas leads to fatal diabetes in all 
animals. In birds pancreatectomy leads to hyperglycemia, cachexia, and 



Fig. 6.—Pancreatic Duct with Branches Showing the Highly Branched Tubules 
Connected with the Duct and with an Islet. Intra vitam staining with pyronin 
and neutral red. X 77. (Bensley.) 

death, but there is said to be little or no glycosuria, because of the relative 
impermeability of the renal epithelium of birds to sugar. 

Following the fundamental discovery of pancreatic diabetes by von 
Mering and Minkowski in 1889, a great amount of work had been done 
to elucidate the nature or mechanism of this diabetes (cf. Allen, 1914). 
The following facts are established: 

1. Hyperglycemia and glycosuria appear within a few hours after 
pancreatectomy, and, together with polyuria, polyphagia, and polydipsia, 
persist until shortly before death, even when no food is given. If the 
hyperglycemia of human or experimental diabetes is sufficiently marked, 
the sugar appears in the saliva, gastric and pancreatic juice, and in the 
bile (Carlson and Ryan, Pearce). 


THE PANCREAS 


689 


2. The liver and the muscles become practically free from glycogen, 
but the essential factor appears not to be the inability to store glycogen 
(alimentary glycosuria) but a greatly diminished capacity, if not com¬ 
plete inability to oxidize the sugar. It is, of course, possible that all 
carbohydrates must first be built up into animal starch or glycogen, before 
oxidation, but this seems improbable since this implies some structural 
differences in the glucose molecule before and after being a member of 
the glycogen complex, and we have as yet no evidence that this is the 
case. The respiratory quotient is, therefore, low (Murlin and Kramer). 
Nishi states that perfusion of the liver of pancreatectomized turtles with 
Ringer’s solution plus glucose leads to storage of glycogen in the liver 
cells. 

3. There is marked polyphagia (Luckhardt) and a striking increase 
(15 to 20 per cent) in the total metabolism per unit of body weight 
(Morehouse, Patterson, and Stephenson). There is no rise in the respira¬ 
tory quotient after giving glucose or fructose. The increased excretion 
of the acetone bodies parallels the increase in the D: N ratio. 

4. There is usually some acidosis and ketonuria, but these symptoms 
of diabetes are, at least in the dog, not as marked as in clinical diabetes, 
and the completely pancreatectomized animals die apparently from ex¬ 
treme inanition or from intercurrent infections rather than in diabetic 
coma due to acidosis. 

5. When the pancreas remnant is too small to maintain normal sugar 
tolerance and metabolism, the pancreas rest is more likely to undergo 
gradual atrophy than to show hypertrophy, with the end result of abso¬ 
lute and fatal diabetes (Sandmeyer). The incomplete diabetes in animals 
following extirpation of more than 85 per cent of the pancreas can 
apparently be intensified, and the appearance of complete diabetes and 
death hastened by a liberal carbohydrate diet (Thiroloix, Allen, Carlson 
and Jensen). 

6. Complete pancreatectomy leads to death in from three to eight 
weeks, in the case of dogs, irrespective of the age of the animal (Carlson), 
while diabetes mellitus is usually more rapidly fatal in children than in 
adults and in old people. 

7. The persistent hyperglycemia and glycosuria and the low respira¬ 
tory quotient show that the pancreatectomized animal burns practically 
no sugar, yet the study of the sugar oxidation capacity of the blood and 
of individual tissues like skeletal muscles and the heart have so far revealed 
no difference between the normal and the diabetic animal (Claus and 
Embden, MacLean, McGuigan, Patterson and Starling, Macleod and 
Pearce). The respiratory quotient of the dog’s heart averages 0.71 irre¬ 
spective of whether the heart is that of a diabetic or a normal dog (Starling 
and Evans). But Hepburn and Latchford have recently reported that 
adding a purified pancreatic extract (insulin) to the perfusing fluid 


690 ORGANOTHERAPEUTICS 

increases the glucose consumption of the excised and perfused mammalian 
heart. 

Certain other features of experimental pancreatic diabetes may be 
noted. Epstein and Baehr claim that there is an increase in the blood 
volume (plasma) in dogs and cats after pancreatectomy, irrespective of 
whether the animal is fed. Hoskins and Gunning state that in dogs after 
complete pancreatectomy the blood-pressure remains either normal or 
somewhat depressed. Reaction to adrenalin is usually augmented; to 
nicotin variable but usually depressed. There is no evidence that the 
pancreas normally exerts a depressive action on the sympathetic nervous 

system. They found 
no evidence of increase 
in the adrenalin con¬ 
tent of the adrenals 
after pancreatectomy. 

Verzar and Fejer 
claim that administra¬ 
tion of glucose during 
the first three to four 
days after pancrea¬ 
tectomy raises the res¬ 
piratory quotient. 
This, if true, would 
indicate that the pan¬ 
creas hormone persists 
in the blood and 
tissues for several 
days. This is prob¬ 
able. It must be 
remembered, however, 
that all the sugar of 
the food or from the endogenous protein metabolism does not appear in 
the urine even in animals and patients showing the D: N ratio of 3.65:1, 
which Lusk has designated as the index of absolute diabetes. It is not 
known what becomes of the retained sugar. In diabetic patients “the 
respiratory quotient fails to account for all the carbohydrates that dis¬ 
appear in the body 77 (Allen and DuBois). 

Numerous attempts have been made to explain the glycosuria of dia¬ 
betes by the increased rate of liberation of the sugar from some hypo¬ 
thetical sugar protein or sugar-colloid combinations in the blood. The 
dialysis experiments of Van Hess and McGuigan seem to demonstrate 
that all the sugar in the blood is present in simple solution, that is, in 
free form. 

The carbohydrate tolerance varies greatly in different species. It is 







Fig. 7.—Small Portion of an Islet of Langerhans 
of the Guinea Pig. Shows B cells filled with 
fine granules, and A cells stained diffusely; a, A 
cells. X 1066. (Bensley.) 



THE PANCREAS 


691 


very low in the pig and the sheep (Carlson and Drennan, Hunter and 
Hill). In normal persons four hundred to five hundred grains of glucose 
may be given by mouth without inducing polyuria or glycosuria (Taylor 
and Hulton). In normal men and animals the oxidation of sugar is in¬ 
creased in proportion to the quantity of sugar given intravenously up to a 
very high limit (Woodyatt). 

The endeavor to determine how absence of the pancreas causes dia¬ 
betes is practically a record of repeated failures. The leading idea in 
all this work has been the internal secretion theory, or that the pancreas 
yields some substance to the blood in some way necessary for the oxidation 
of the sugar by the tissue cells. The new method of attack introduced 
by Cohnheim has not yielded consistent results (Claus and Embden, Mc- 
Guigan), and in the light of the findings of Levene and Meyer the method 
itself is called in question, as it appears that in a mixture of muscle extract 
and pancreas extract glucose is polymerized, not oxidized. No light on 
pancreatic diabetes has so far been shed by studying the sugar oxidizing 
power of tissue debris or tissue extracts. 

Blood Transfusion.—If the pancreas controls the oxidation of sugar 
in the tissue by a hormone or hormones, these must be present in the 
blood, and unless they are extremely unstable or present in very minute 
traces, it should be possible to increase temporarily the sugar oxidation 
in diabetic animals and patients by transfusion of normal blood in suffi¬ 
cient quantities. But the results obtained by this method are both con¬ 
flicting and difficult to interpret. 

Lepine reports a temporary diminution in the output in the urine, 
but no diminution in the blood sugar. This would seem to point to some 
injurious action of the foreign blood on the kidneys a suggestion also 
advanced by Hedon—but Rabens has shown that transfusion of normal 
blood into diabetic dogs does not influence the output of any of the urinary 
constituents except the sugar. Hess injected intravenously 50 to 150 c.c. 
of blood from diabetic dogs into normal dogs (on the theory that diabetic 
blood might stimulate the pancreas to a greater output of internal secre¬ 
tion) and nine to fourteen hours later he injected the serum from this 
animal into diabetic dogs. The influence on the glycosuria of the diabetic 
animal was slight or inconstant. In view of the results of Drennan, it 
seems likely that in the experiments of Hess the pancreas secretion in 
the blood was destroyed by the delay in centrifuging the blood. Alexander 
and Ehrmann injected blood from the pancreaticoduodenal vein of normal 
dogs into diabetic dogs, but obtained no definite or constant decrease of 
the glycosuria. 

Drennan injected 50 to 150 c.c. of fresh defibrinated dogs' blood into 
the veins of diabetic dogs and invariably obtained a temporary lowering 
of the urine sugar and the D: N ratio. Defibrinated sterile blood loses 
this action on standing for a few hours. The course of the blood sugar 


692 


ORGANOTHERAPEUTICS 


in the injected animals was not studied. Hedon has reported a very exten¬ 
sive series of blood transfusions in diabetic dogs. Direct transfusion 
from a normal dog into a diabetic dog previously bled dry causes a 
temporary lowering of the blood sugar and decrease or complete suppres¬ 
sion of the glycosuria, but, since the same results were produced when 
blood from a diabetic dog was transfused into another diabetic dog, Hedon 
concludes that the temporary diminution of the hyperglycemia and glyco¬ 
suria following the transfusion was not due to any specific pancreas secre¬ 
tion in the blood but to a lowering of the blood sugar by dilution and 
to a toxic action of the foreign blood on the kidneys. The results of 
the cross-transfusion experiments reported by Hedon do not concern us 
here, since these may be interpreted in various ways (detoxication of the 
pancreas, storage of glycogen in the normal animal, dilution of the diabetic 
blood, etc.). Hedon also transfused (cross-transfusion as well as serum 
injections) blood from the pancreatic vein of normal to diabetic dogs. 
A slight temporary lowering of the hyperglycemia with a greater reduc¬ 
tion of the urine sugar was noted, but the latter is interpreted as due 
to an injurious action of the foreign blood on the kidneys. Hedon con¬ 
cludes that the internal secretion of the pancreas acts on and is absorbed 
by the liver and is, therefore, not present in the blood of the systemic 
circulation. Hedon attempted to obtain evidence in support of this view 
by introducing a living pancreas in the systemic and in the portal circula¬ 
tion of diabetic dogs. With the living pancreas interposed in the portal 
circulation the hyperglycemia and glycosuria were diminished, hut 
when it was interposed in the general circulation the pancreas had no 
effect. 

We do not think that these latter results of Hedon can be accepted, 
in view of what is known concerning the carbohydrate metabolism in dogs 
with Eck fistula. In the animal with the Eck fistula the internal secre¬ 
tion of the pancreas, if there is one, must pass into the general circula¬ 
tion, and only a small part of it can reach the liver bv way of the hepatic 
artery, just as in Hedon’s diabetic dogs with the living pancreas from 
another dog interposed in the general circulation; yet the Eck fistula 
dog does not develop diabetes. 

Murlin and Kramer reported one experiment with transfusion of 
normal blood into a diabetic dog showing slight rise in the respiratory 
quotient, as a measure of sugar oxidation. 

Carlson and Ginsburg found that the transfusion (without anesthesia 
or previous hemorrhage) of normal blood into dogs in complete pancreatic 
diabetes causes a temporary (four to eight hours) lowering of the hyper¬ 
glycemia and the glycosuria. Similar transfusions of diabetic blood into 
diabetic dogs have no effect on the hyperglycemia. There was no indi¬ 
cation in these results that the sugar retained by the animal in conse¬ 
quence of this temporary lowering of the sugar excretion by the kidneys 


THE PANCREAS 


693 


is subsequently eliminated by the kidneys as excess sugar, as suggested 

by Murlin. 

The blood transfusion as such does not impair the kidneys’ activity 
in any demonstrable way, either in diabetic or in normal dogs. The tem¬ 
porary lowering of the glycosuria of pancreatic diabetes by transfusion 
of normal blood is due to the diminished hyperglycemia, not to kidney 
injury, but it remains to be demonstrated that this retained sugar is 
actually oxidized by the tissues. 

Parabiosis.—Experimental symbiosis or parabiosis of two mammals 
is accomplished usually by union of the skin and the abdominal walls 
of two sisters or brothers. It was originally thought that such union of 
two animals would lead to a direct vascular connection between the two, 
but it is now known that this is not the case. There is no fusion of the 
capillary systems of the two animals in the region of the tissue union; 
but the capillary systems of the two animals are in so close contact that 
chemical substances injected into one animal soon appear in the blood 
of the other animal. On the basis of this fact one may reasonably expect 
that the blood hormones of one animal will find their way into the body 
fluids of the other animal. On this theory Forsbach extirpated the pan¬ 
creas of one member of two such parabiotic pairs (dogs). In every case 
a slight temporary glycosuria appeared in both animals. But because 
of accidents both experiments were terminated before definite results 
were obtained. 

Pregnancy.—It was shown by Pearce that the islets of the pancreas 
appear early in fetal life. There appears to be no diabetes or glycosuria 
in human infants born two or three months before term. This would 
seem to show that the pancreas hormones become of functional importance 
to the fetus a considerable time before the end of gestation. On the basis 
of these facts Carlson, Drennan, Orr, and Ginsburg made complete pan¬ 
createctomy in pregnant bitches near term. In all cases where this opera¬ 
tion is not followed by abortion, the blood sugar and the urine remain 
normal until the pups are born, or removed by cesarian section. Complete 
pancreatectomy in bitches in early pregnancy leads to abortion, or at 
least to death of the fetuses, in one or two weeks and the course of the 
diabetes is not influenced. 

This absence of diabetes may be due either to the pancreas hormones 
of the fetuses passing into the mother’s blood or to some detoxicating 
action on the part of the fetal pancreas. 

There is a seeming discrepancy between these results on pregnant 
dogs and the usual clinical experience on the effects of pregnancy on the 
course of diabetes in the human. The clinical experience appears to be 
unanimous on the point that pregnancy augments the diabetic symptoms, 
and hence the practice of terminating gestation in diabetic mothers. Now, 
even if in their primary cause all cases of diabetes mellitus are identical 


694 


ORGANOTHERAPEUTICS 


with that of experimental pancreatic diabetes, the favorable action of 
the fetal pancreas on the mother would come only late in pregnancy, and 
the disturbances in digestion, circulation, and emotional states, etc., of 
the first half of pregnancy would undoubtedly act unfavorably. But, 
so far as we have been able to learn, the unfavorable action of preg¬ 
nancy on clinical diabetes during the second half of gestation is even 
greater than during the first half. If this is true, it would seem to indi¬ 
cate a primary difference in the etiology of diabetes in man and of 






















Pr 

egni 

int ] 

Bitcl 

in 



























l\ 

















r 











A 

Cillec 

L M 

cide 

ntall 

4 











On 

set i 

i La 

bor 





Blood 

Sugai 


Hours after Pancreatectomy 



Fig. 8.—Charts Showing Absence of Hyperglycemia and Diabetes after Complete 
Pancreatectomy in Late Pregnancy. Diabetes begins at onset of labor. (Carl¬ 
son and Ginsburg.) 

experimental pancreatic diabetes in other mammals. The difference, 
however, may be only apparent. If the diabetes in the mother is caused 
by the depression of the pancreas by some substance in the blood, or by 
the inhibition or neutralization of pancreatic secretion by substances in 
the blood, rather than by actual atrophy of islet tissue, these substances 
in all probability would act in the same way on the fetal pancreas or 
pancreatic hormones, thus giving the usual clinical findings. 

Transplantation of the Pancreas.—Most of the transplantations of 
the pancreas have been mere dislocation of a portion of it, the usual 
method being the transplantation of the tail of the pancreas with its cir- 






















































THE PANCREAS 


695 


culation intact, to other parts of the abdominal cavity, or even under 
the skin of the abdomen. If a sufficient quantity of the pancreas is thus 
dislocated or transferred and care is taken to retain the circulation in good 
condition, at least for a time, the remainder of the pancreas may be 
extirpated without inducing diabetes (Thiroloix, Hedon, Lombroso, Min¬ 
kowski). But in most cases even these transplants show a tendency to 
atrophy with a gradual onset of diabetes and ultimate death in complete 
diabetes. The external ferments of the pancreas are probably in part 
responsible for this gradual necrosis of the graft. There is no record 
in the literature of transplantation of pure island tissue. There is cer¬ 
tainly greater hope of success with such tissue than with the entire pan¬ 
creas. Pfliiger failed to influence the diabetes of depancreatized frogs 
by inserting pieces of the pancreas under the skin or in the peritoneum. 
Pratt reports the case of one pancreas autotransplant into the spleen 
(dog) that retained its function (absence of diabetes) for six months. 
But there is little hope of pancreas transplantation becoming of signifi¬ 
cant value in clinical diabetes, since it seems at present impossible to 
heep grafts of any gland permanently functional. 

Feeding Pancreas or Pancreas Extracts.—Feeding dogs in complete 
or partial pancreatic diabetes with fresh pancreas increases the glycosuria 
and acidosis (Sandmeyer, Pfliiger, Liithje, Reach, Rosenberg, Kirk). 
Cooked pancreas gives equally negative results. Feeding of raw muscle, 
liver, or other tissue extracts has the same unfavorable influence on the 
glycosuria. and ketonuria. Ausset, and particularly Pratt, Spooner and 
Murphy report good effects from feeding pancreas in partially diabetic 
dogs, but the improvement in the carbohydrate tolerance was slight, va¬ 
riable, and practically negligible. According to Massagli, feeding pan¬ 
creas extract to guinea pigs with experimental reduction of the pancreas 
reduces or prevents the alimentary glycosuria following carbohydrate food. 

Injection of Pancreas Extracts.—Up to the year 1921 subcutaneous 
or intraperitoneal injections of extracts of the pancreas variously prepared 
caused temporary diminution of the glycosuria in diabetic animals 
(Caparelli, Vanni, Tiberti and Franchetti, Minkowski, Hedon, Zuelzer, 
Scott, Allen, Murlin and Kramer, and others). But this temporary dimi¬ 
nution of the output of sugar in the urine was associated with toxic effects, 
such as depression, fever, etc., and McGuigan showed that almost any¬ 
thing which causes marked systemic depression (such as injection of 
proteoses) leads to hypoglycemia, and will thus temporarily diminish an 
existing glycosuria. Underhill reports diminution of glycosuria in dogs 
by hydrazin. Knowlton and Starling, and Maclean and Smedley reported 
that the sugar oxidation of the heart from diabetic animals is almost nil, 
and in any event much less than that of a heart from a normal animal; 
but further work has shown these results to he due to faulty technic 
(MacLeod and Pearce, and Patterson and Starling). Extract of the 


696 


ORGANOTHERAPEUTICS 


pancreas added to the perfusion solution has no effect on the respiratory 
quotient of the diabetic heart (Starling and Evans). 

This was the unsatisfactory state of our scientific work when, in 
1921, Banting and Best renewed the investigations of pancreas extracts, 
with promising results. They first made extracts of the fetal pancreas, 
and of pancreas rendered atrophic by ligation of the ducts, in order to 
eliminate the external pancreatic secretion. These extracts reduced the 
hyperglycosuria of diabetic animals. Later, in collaboration with Collip, 
acid and alcohol extracts were made of the normal adult pancreas that 
similarly reduced the hyperglycemia of diabetes and lowered the blood 
sugar in normal animals. The extract, or rather the active substance in 
the extract, has been named insulin. Insulin has so far not been prepared 
in pure state, nothing is known of its composition, although Macleod 
has reported that active extracts can be prepared that give no reactions 
characteristic of proteins. The extract is toxic, but according to Macleod, 
at least part of this toxicity is due to the active substance, insulin, that 
is, to the excessive hypoglycemia caused by excessive doses of the insulin. 
The experimental results to date (January, 1923) reported by Banting, 
Best and their collaborators and workers in other institutions can be 
summarized thus: 

1. The pancreas extract, insulin, lowers the blood sugar both in 
diabetes and normal animals. This seems to be due to two processes: 

(1) increased formation of glycogen by the liver and the muscles; and 

(2) increased oxidation of sugar, as shown by the rise in the respiratory 
quotient. This action of the extract is temporary (6 to 8 hours). 

2. Continued administration of the extract seems to maintain nutri¬ 
tion and prolong the life of depancreatized dogs, but the work on this 
phase is not yet conclusive. 

3. The extract has little or no effect when given by mouth or per 
rectum. It must be administered parenterally. 

4. The toxic effects (depression, convulsion, death) from large doses 
are assumed to be due to the hypoglycemia, since these effects can be, 
at least in part, prevented by the administration of glucose. 

5. The insulin does not seem to be entirely specific for the pan¬ 
creas, as extract producing some hypoglycemia can be secured from other 
organs by identical methods of preparation. But Macleod reports that, 
in fishes, insulin is obtained from the island of Langerhans and not from 
the pancreas proper. 

6. Some fraction of the pancreas extracts actually produces hyper¬ 
glycemia in normal animals (Fisher). 

Pancreas Hormones in Pancreatic Perfusates. —Clark placed the pan¬ 
creas in the perfusion circuit of an excised heart, perfused with Locke’s 


THE PANCREAS 


697 


solution containing known quantities of glucose. He reported that under 
these conditions the heart consumed more glucose than did the heart 
without a surviving pancreas in the circuit. Clark interpreted this as 
proving that the pancreas secreted into the perfusate some substance that 
accelerated the sugar oxidation by the heart. Landes, et al., perfused 
the excised pancreas with Tyrode’s solution for varying periods, and in¬ 
jected the perfusate intravenously into diabetic dogs. There was no 
reduction of the hyperglycemia and glycosuria. There is no evidence that 
the excised pancreas perfused with a Ringer sugar solution is sufficiently 
normal to secrete the hormone. Clark’s results might be explained 
by death and solution of the island cells. It is well known that per¬ 
fusion of organs with salt solutions quickly induce pathological changes 
(edema). 

The perfusate takes up depressor substances (peptones?) from the 
pancreas. In order to eliminate these sources of error McCarthy and 
Olmstead, in our laboratory, perfused the excised pancreas (using the 
Woodyatt pump) of the dog with defibrinated blood from the same ani¬ 
mal, and then injected the blood intravenously into diabetic dogs. Con¬ 
trol experiments were made by perfusing the excised spleen. In other 
control experiments active secretin was added to the defibrinated blood 
in order to see whether the excised and perfused pancreas was sufficiently 
alive and normal to secrete pancreatic juice. In most cases a slight 
secretive response (a few drops) was obtained, but this was much less 
than the usual response of the intact pancreas to similar doses of secretin. 
It is, therefore, clear that even when the excised pancreas is perfused 
with blood the pancreas is so abnormal or depressed that it is doubtful 
if any normal function is present. Intravenous injection of this pan¬ 
creas perfusate into diabetic dogs usually lowered the hyperglycemia, 
but did not constantly lower the D: N ratio of the urine. That these 
were toxic rather than physiological effects seems to be shown by the fact 
that identical results were produced by the spleen perfusate. It would 
seem that perfusing the excised pancreas leads to demonstrable quantities 
of the pancreas hormone in the perfusate only to the extent that island 
cells are killed and extracted. 

Relation of Pancreatic Diabetes in Animals to Clinical Diabetes. —In 

their essential features, experimental and clinical diabetes are practically 
identical. There is the same impairment of the power to burn sugar, 
the identical hyperglycemia, tendency to acidosis, lowered resistance to 
infection, polyphagia, etc. The two types of diabetes are influenced in 
the same direction by diabetic and therapeutic measures (Allen). All 
the evidence points to the view that diabetes mellitus in man is primarily 
due to deficiency or inhibition of pancreatic hormones. This does not 
apply to the various glycosurias (adrenalin, nervous, alimentary, post¬ 
operative, etc.) which do not involve impairment of sugar oxidation. 


698 


ORGANOTHERAPEUTICS 


Administration of Pancreas Preparation (Insulin) in Clinical Dia¬ 
betes by the Mouth. —Some of the earliest attempts to treat diabetes 
mellitus organotherapeutically were by the administration of the pancreas 
by the month; it was largely abandoned very early, for the results were 
practically negative (Mackenzie, Wood, White, de Cerenville, Willis, 
Williams, Rennie and Fraser, Pratt, Wood, Marshall). 

A few writers (Wegele, Meyer, Cowles and Eustis) have reported fav¬ 
orable results. Some of these reports contain only impressions, in others 
the glycosuria seemed dependent upon an infection and varied so much 
in severity that it is difficult to determine what, if any, effect the treat¬ 
ment had. In Cowles’ case the diabetes had followed an abscess of the 
pancreas; marked and rapid improvement is stated to have followed the 
eating of one to six (average three) raw pancreases of calves daily. 
After discontinuing the treatment the patient became rapidly worse and 
died, as he probably would have done had the pancreas feedings been 
kept up. 

Rennie and Fraser administered the islands of Langerhans obtained 
from fish of certain species in which they occur separately, that is, dis¬ 
tinct from the pancreas proper, to a number of diabetics; the results were 
negative. 

Sewall found in the earlier stages of one case of youthful diabetes 
that the urine could be made free of sugar by the administration by mouth 
of infusions of raw, lean beef followed, after some hours, by one of 
pancreas; neither alone was efficacious, and after some months the com¬ 
bined treatment failed. The method was ineffective in a number of other 
cases. JSTo good results attended the use of the commercial pancreatic 
powder. 

Under the influence of the first report of Knowlton and Starling on 
the effect of pancreas extract on the sugar consumption of the diabetic 
heart, Eustis administered 10 to 20 grains of an “active extract of the 
pancreas” every four hours on an empty stomach in four cases of diabetes. 
He reports diminution of the glycosuria in two of the patients and no 
effects in the others. The insulin of Banting and Best appears to have 
no effect when given per os or per rectum , or by means of the duodenal 
tube. 

There is, however, according to Falta, a small group of cases of 
human diabetes in which the administration of pancreas by mouth gives 
good results: this is the result of supplying the external and not the in¬ 
ternal secretion of the gland. Falta refers to those cases in which the 
pancreas is diseased, so that there is no longer an adequate secretion of 
pancreatic juice into the intestine; this occurs most frequently when 
there is complete obstruction of the pancreatic duct. In such cases Falta 
states that the administration of large doses (10 grams daily) of pan- 
creatin gives excellent results. According to Cody and Rooper, feeding 


THE PANCREAS 


699 


pancreas vitamin to marasmic children stimulates growth and improves 
nutrition. This is food therapy, not organotherapy. 

Subcutaneous and Intravenous Injections of Pancreas Preparations. 
—A number of attempts have been made to treat diabetes by subcutaneous 
and intraperitoneal injections of extracts of pancreas, with negative or 
injurious results. The favorable results reported by some of the earlier 
clinicians were shown by Pfliiger and by Leschke to be wholly inconclusive. 
I he more recent attempts of Zuelzer to treat the disease by the intra¬ 
venous injection of a “pancreas hormone” was given up largely because 
of toxic effects of the extract. During the last year the insulin of 
Banting and Best has been tried on selected cases of human diabetes in 
the United States and Canada. It is too early to reach definite con¬ 
clusions as to the ultimate value of insulin, but so far the results are 
encouraging (Banting et al .). In sufficiently large doses three times per 
day (hypodermatically) insulin seems to control all the symptoms in most 
diabetic people and permit a larger food intake. Some diabetics are less 
favorably influenced by insulin. These may not be cases of pancreatic 
diabetes. The main drawback to the insulin treatment is the toxicity of 
the extract and the necessity of such frequent hypodermic administration. 
Dietary control will probably always be a factor in the management of 
diabetes, unless insulin therapy for shorter periods may increase the 
carbohydrate tolerance more or less permanently. 

Fortunately, few attempts have been made to treat human diabetes 
by transplantation of the pancreas, Futcher states that Williams, of 
Bristol, transplanted the pancreatic gland of a sheep under the skin of the 
breast and abdomen of a diabetic. The patient died of coma in three days. 

Blood Transfusion.—Baulston and Woodyatt appear to be the first 
to try blood transfusion as a practical therapeutic measure in man. The 
patient was a man in the thirties, the diabetes of several years’ stand¬ 
ing with periods of threatening coma. The blood (500 c.c.) was yielded 
by a two-year older brother of the patient. The experiment was well 
controlled. The blood transfusion augmented all the diabetic symptoms 
for several days following the operation. 

Relation of Other Endocrine Glands and Organs to Experimental 
and Clinical Diabetes.—In 1908, Eppinger, Falta and Rudinger advanced 
the theory that diabetes is not due primarily to the hypofunction of any 
one endocrine gland (for example, the pancreas), but to a disturbance of 
the hormone equilibrium of all the glands—particularly that of the pan¬ 
creas, thyroid, adrenals and hypophysis. This view is still held by some 
(Brown, Hatai). The specific influence on carbohydrate metabolism of 
hypofunction and hyperfunction of the adrenals, thyroid and hypophysis 
are discussed in the sections on these glands respectively. It now remains 
to consider whether the hypofunction or hyperfunction of any other 
organ beside the pancreas is capable of so reducing the capacities of the 


700 


ORGANOTHERAPEUTICS 


tissues to store and oxidize sugar that true diabetes follows. A critical 
analysis of the entire literature, experimental and clinical, seems to war¬ 
rant the following conclusions: 

1. Hypo-activity of the thyroid, the hypophysis and the gonads may 
slightly change carbohydrate tolerance, although further studies should be 
made on this question by Woodyatt’s more accurate method of measuring 
sugar oxidizing capacity. If true, this may be in reality a thyroid factor, 
as there is some indication of hypertrophy of the islets, at least after 
thyroidectomy. 

2. Excessive administration of epinephrin, thyroid extract, and pos¬ 
sibly hypophyseal extract, may induce temporary hyperglycemia and gly¬ 
cosuria due to increased sugar mobilization. But there is no evidence 
that this glycosuria is, or passes Into, true diabetes, that is lowered power 
to bum sugar, in the absence of a direct pancreas depression. This ap¬ 
plies also to disturbances of the nervous system. 

3. The precise influence of the hypo-activity or hyperactivity of the 
adrenals, thyroid and hypophysis on the islets of the pancreas cannot at 
present be definitely stated, but it is obvious that organs which are as 
necessary to life, that is, to healthy normal life, as the parathyroids, the 
adrenals, the hypophysis, and the thyroid will affect the vital processes 
of the islet tissue, at least indirectly, through the general disturbance of 
metabolism and the circulation. 

After a careful experimental and critical review of the entire question, 
Allen states that the “polyglandular equilibrium doctrine of diabetes has 
consisted from the first of ingenious but unfounded speculations.” We 
are in entire accord with this conclusion. 

The attempt of Pfliiger to show that diabetes is due, not to hvpofunc- 
tion or loss of the pancreas, but to interference of nervous reflexes from 
the pancreas to the duodenum and the liver has already been referred to. 
Any general reflex theory of diabetes is untenable in view of the fact 
that every organ so far investigated continues to oxidize sugar after com¬ 
plete denervation. The loss of the sugar oxidizing capacity is, there¬ 
fore, a hormone, not a reflex phenomenon. But the building up of gly¬ 
cogen, especially by the liver, appears to be partly under nervous control. 

Other workers have pointed to the probable importance, direct and 
indirect, of the gastro-intestinal tract in diabetes. Case has recently re¬ 
ported a striking parallel between the severity of clinical diabetes and the 
degree of ileal stasis. If the ileal stasis is a primary factor this would 
point to intestinal intoxication depressing the pancreas as a contributory 
factor in diabetes. 

The administration of sodium carbonate reduces temporarily the 
glycosuria of depancreatized dogs. This fact has led Murlin to suggest 


THE SUPRARENAL GLANDS 


701 


that the diabetes following extirpation of the pancreas may be due, in 
part, to the unneutralized HCL of the stomach secretion. Murlin and 
Sweet have removed the stomach in depancreatized dogs, and find that 
the glycosuria is less severe than with the stomach intact. But such ani¬ 
mals are probably more depressed than after pancreatectomy alone, and 
the low output of sugar may be due to this condition. 

Summary 

1. All the evidence supports the view that some substance or hormone 
secreted by the islands of Langerhans into the blood is necessary for the 
building up of glycogen and oxidation of sugar by the tissues. This 
function is specific for the pancreas. Other endocrine organs (adrenals, 
thyroid) may influence sugar metabolism in a superficial way by alter¬ 
ing the sugar mobilization, or by increasing or decreasing the rate of 
oxidation in the body in general. The rest of the endocrine glands can¬ 
not maintain the power of the tissues to oxidize sugar in the absence 
of the pancreas, and the hypo-activity or hyperactivity of other endocrine 
glands does not produce diabetes in the presence of a normal pancreas. 

2. While the failure of the tissues to burn sugar in the absence of the 
pancreas is the central and definitely established fact, there are probably 
other primary defects and equally important impairments involved in the 
development of acidosis, increased metabolism, lowered resistance, infec¬ 
tion, lipemia, etc. 

3. All the evidence points to the view that true diabetes mellitus in 
man is primarily the result of pancreatic (islets) deficiency, or inhibition 
of the islet hormones on the tissues. 

4. The insulin of Banting, Best, Collip and Macleod may prove.to be 
a specific and useful substance in the control of diabetes. But so far as 
the evidence now stands it is not a cure, and the dietary control of diabetes, 
as developed especially by Allen, Newburg and others, will probably al¬ 
ways constitute a necessary factor in the therapy of diabetes. 

5. There is no evidence that the various pancreas extract preparations 
on the market, advertised as active when given by mouth, are of any value 
in diabetes. 


THE SUPRARENAL GLANDS 

Anatomy.—The suprarenal glands of man and the higher animals 
consist of at least two distinct tissues. The cortex is of mesodermal origin 
and belongs to a system known as the iTitcvreYial system. The medulla 
is of ectodermal origin, starting as a part of the sympathetic nervous 
tissues. It is a part of the “adrenal” or “chromaffine” system (so called 


702 


ORGANOTHERAPEUTICS 



from its affinity for the salts of chromic acid). A very considerable 
amount of chromaffine tissue is found in man outside of the suprarenals 
(in small masses along the sympathetic nerves and in the carotid gland); 
interrenal tissue is also often found in other parts of the body outside 
of the suprarenals. 

These two parts are anatomically separated in some fishes, but in man 
and the higher animals they are so intimately connected that it is very 

difficult to study their 
functions separately, 
and most of the know¬ 
ledge on this subject is 
based upon observa¬ 
tions and experiments 
upon the entire organ. 
Accessory suprarenals 
(medullary tissue, or 
cortical tissue, or both 
combined) occur in 
some animals, par¬ 
ticularly the rat. 

The cortex is made 
up of polygonal epithe¬ 
lium-like cells ar¬ 
ranged in columns, and 
rich in a double refrac¬ 
tive lipoid substance. 
In the pig this lipoid 
makes up 38.8 per cent 
of the dry cortical res¬ 
idue (Biedl). 

The fetal adrenals 
are relatively large, 
at one stage the cortex 
extending throughout 
the whole length of the body cavity. The female rat has a larger adrenal 
gland than the male. In other species such sex differences have not been 
made out, but there appears to be some hypertrophy of the adrenal cortex 
associated with the periods of rut and pregnancy. In man there occur 
certain degenerative changes that lead to diminution of the adrenal cortex 
during the first two weeks after birth (Lewis and Pappenheimer). The 
modified nerve cells of the medullary portion are characterized by their 
brown color reaction with chronic acid (chromaphile reaction). This 
chromaphile tissue has been found in certain parts of the nervous system 
and in the skin of various invertebrates. In the American toad (Bufo 


Fig. 9.—Section of Suprarenal of Child Twelve Days 
Old, Low Power. A, outer part of cortex; B, large 
cells forming boundary zone of cortex; C, thin layer of 
medulla; just below is the central vein. (Elliott and 
Armour.) 



THE SUPRARENAL GLANDS 703 

aqua) it is present in part of the skin, and the skin secretion of this 
animal is reported to contain epinephrin (Abel). 

The suprarenal gland has a very rich blood supply. According to 
Neumann the blood supply to these glands is greater than to any other 
organ in the body, or 6 to 7 c.c. per gram of gland per minute. This 
enormous blood supply is undoubtedly of significance in relation to the 
secretory and, possibly, detoxicating functions of the gland. 

Each adrenal gland receives numerous nerve filaments from the 
splanchnic nerves and the adrenal plexus. The nerve filaments are dis¬ 
tributed both to the cortex and the medulla, part of the fibers passes to 
the blood-vessels (vasomotor nerves) and part appears to end around 
the gland cells (secretory nerves?). True sympathetic nerve cells are also 
found both in the cortex and in the medulla. Nothing is known concern¬ 
ing sensory nerve supply to the adrenals. 

Chemistry of Medullary Tissue.—Oliver and Schafer showed that 
extracts of the medulla of the suprarenal glands, when injected intra¬ 
venously, caused a marked rise of blood-pressure. 

The chemical work of Abel, von Fiirthj Takainine, Aldrich, Dakin, 
Stolz, Flacher, and others resulted in the isolation of and, later, synthesis 
(from coal-tar derivatives) of a definite chemical compound named by 
Abel epinephrin, by Takamine adrenalin ,, Chemically this compound is 
dioxyphenylethylolmethylamin (C 9 H 13 N0 3 ). It is levorotatory. The 
compound made synthetically is optically inactive, and has only about 
one-half of the physiological activity of the natural compound (Cushny, 
Schultz). It can, however, be separated into two optically active isomers, 
one of which, the levorotatory compound, seems identical in every respect 
with the natural base. Epinephrin is present in all chromaphile tissues 
(Vincent, Fulk and Macleod). It appears very early in the fetal adrenals, 
at least in most species (McCord, Fenger, Cevolatto, Langlois and Rehns). 
But Lewis failed to detect epinephrin in the fetal adrenals in man. This 
is important in view of the fact that there is no evidence of adrenal in¬ 
sufficiency in prematurely born infants. If epinephrin is absent in the 
human fetus in late gestation (seven to eight months), this substance is 
evidently not necessary for life. 

It is estimated that the normal adrenals of adult persons contain at 
any one time only a few milligrams (8 to 9) of epinephrin (Elliott). 
The adrenals of normal dogs contain 1 to 2 milligrams of epinephrin 
(Sydenstricker). Trendelenburg reported that the adrenals of the cat 
secrete into the blood about 0.003 milligram of epinephrin per minute or 
about 5 milligrams per kilo body weight in twenty-four hours. Hoskins 
and McClure estimated the output of epinephrin in the dog as 0.2 c.c. 
of a 1: 1,000,000 dilution of epinephrin per minute per kilo body weight. 
The same authors found that the blood of the general circulation (dog) 
contains epinephrin in the concentration of 1: 200,000,000. Trendelen- 


704 


ORGANOTHERAPEUTICS 


burg states that the epinephrin content of the carotid blood of the normal 
rabbit does not exceed one part to two milliards of blood. Stewart and 
Rogoff give the following figures for the average rate of epinephrin se¬ 
cretion (animals under light anesthesia) per kilo body weight of animal: 
cat, 0.00025 milligram; dog, 0.00022 milligram; monkey, 0.0002 milli¬ 
gram ; rabbit, 0.0003 milligram. 

Epinephrin is a rather unstable body. It is oxidized or destroyed 
only slowly in the blood, but rapidly by the tissue and the walls of the 
blood-vessels (Tatum). Hence, giving epinephrin by mouth is prac¬ 
tically without physiological effects. 

Tonus Theory of Adrenal Function.—It seems well established that 
the suprarenal glands under normal conditions secrete epinephrin into the 
blood of the adrenal veins continuously and at a remarkably constant rate. 
It was formerly supposed that enough epinephrin is thus secreted by the 
normal adrenals to maintain a steady stimulation of, or tonic action on, the 



Fig. 10.—Effects of Intravenous Injection of Adrenal Extract (Epinephrin) 
on the Heart and the Blood-Pressure. (Oliver and Schafer.) 


heart and the blood-vessels, thus aiding in the maintenance of the normal 
blood-pressure. This constituted the so-called tonus theory of adrenal func¬ 
tion. The work of Cannon, Hoskins, Stewart, and others has rendered 
this tonus theory untenable, for the following reasons: 

1. The quantity of epinephrin secreted into the blood under ordinary 
conditions is too small to have any appreciable effect on the heart or the 
blood-vessels. Hoskins found that it requires 0.42 c.c. of a 1: 1,000,000 
epinephrin per kilo body weight per minute to affect the blood-pressure 
in the dog, and this minimum quantity causes vasodilatation, not vaso¬ 
constriction (Cannon, Hoskins). The normal output of epinephrin by 
the dog’s adrenals is only 0.2 c.c. of this epinephrin concentration per 
minute. The maximum concentration of epinephrin in the adrenal veins 
is 1:500,000 (Stewart and Rogoff). Even assuming that there is no 
destruction of epinephrin until it reaches the systemic capillaries the 
dilution of this substance in the arterial blood will be 1: 500,000,000 or 
1 : 1 , 000 , 000 , 000 . 



THE SUPRARENAL GLANDS 


705 


2. The quantity of epinephrin in the blood sufficient to raise the 
blood-pressure or to affect the blood-pressure is more than sufficient to in¬ 
hibit the motility of the gastro-intestinal tract. In fact the gastroin¬ 
testinal tract is more sensitive to the inhibitory action of epinephrin than 
the heart and the blood-vessels to its tonic or stimulation action. Hence, 
as long as gastro-intestinal motility is present there is not enough epi¬ 
nephrin in the blood to influence the tone of the heart and the blood-vessels. 

3. Complete or practically complete suppression of epinephrin secre¬ 
tion by section of the adrenal nerves does not induce lowering of the blood- 
pressure or impairment of the heart. 

4. The minimum effective dose of epinephrin causes a fall, not a rise 
of blood-pressure. 

Emergency Theory of Adrenal Function.—This theory was proposed 
by Cannon in 1914, based partly on data already in the literature, partly 
on work by Cannon and his associates. This theory assumes that under 
conditions of marked physiological stress, such as pain, anger, fear, other 
intense emotions, asphyxia, etc., there is a sufficiently increased secretion 
of epinephrin to have physiological and useful action for the survival of 
the animal. In support of this theory Cannon musters the following 
arguments: 

1. It seems well established that hypodermatic or intravenous injec¬ 
tions of suitable quantities of epinephrin stimulate the heart, raise the 
arterial blood-pressure, increase the coagulability of the blood, mobilize 
the liver glycogen in the form of increased blood sugar, increase the 
resistance to fatigue of the skeletal neuromuscular mechanisms, increase 
the coagulability of the blood, and induce a temporary polycythemia. 

2. It is also established that direct stimulation of the peripheral end 
of the splanchnic nerves causes sufficient augmentation of epinephrin out¬ 
put to have demonstrable physiological effects (rise in blood-pressure, dila¬ 
tion of the pupils, etc.). 

3. That stimulation of the sciatic (pain), asphyxia, anger,. etc., acts 
on the epinephrin secretory nervous mechanism in the way of stimulation. 
Cannon and his coworkers, Anrep and others, have tried to prove by the 
behavior of the denervated heart under these conditions before and after 
adrenalectomy; also by direct essay (intestinal strip) of the epinephrin 
content of the blood; by vasoconstriction in the denervated leg, by the re¬ 
action of the denervated pupil and by increased secretion in the de¬ 
nervated salivary gland. Some of these tests were made without anesthesia, 
and the reported results indicate that sciatic stimulation (pain), asphyxia, 
and strong emotions cause increased secretion of epinephrin. 

Stewart and Rogoff have repeated or checked all of these experiments 
both with the original methods, and with improved methods of their own, 


706 . 


ORGANOTHERAPEUTICS 


but failed to secure any evidence of reflex (pain), asphyxial or emotional 
stimulation of the adrenal medulla. 

The theory has thus far no unchallenged experimental support. Even 
if future work should prove the theory tenable, it must be shown that 
animals with denervated adrenals are handicapped in their natural en¬ 
vironment. If that is not the case, the reaction may have no greater 
biological significance than the blushing that may or may not follow the 
feeling of embarrassment in some people. 

Theory of Epinephrin Control of Functions of Blood Capillaries.— 
Extensive studies on dogs, cats and rabbits led Gradinescu to conclude 
that the suprarenal secretion controls metabolism by controlling the perme¬ 
ability of the blood capillaries, and hence the exchange between the blood 
and the tissues. He claims that adrenal deficiency causes the blood-plasma 
to pass into the tissue spaces and the body cavities to such an extent 
that the concentration of blood-corpuscles becomes twice as great as the 
normal. The viscosity of such blood is obviously great and the circula¬ 
tion correspondingly impeded. But it is possible that the transudation of 
plasma from the blood noted by Gradinescu is in reality an effect from the 
impaired circulation (cardiac edema). But Donath maintains that change 
in capillary permeability is a factor. This theory should be reinvestigated 
in the light of the recent work of Krogh and others on the nervous and 
chemical control of the blood capillaries. 

Secretion of the Epinephrin.—Direct stimulation of the splanchnic 
nerves increases the output of epinephrin (Biedl, Dreyer, Cannon, Elliott 
and others). It is generally assumed that this is a true secretory action 
of the adrenal nerves on the medullary cells. But the stimulation of the 
splanchnics causes at the same time vasodilation of the suprarenals, while 
it is well known that this stimulation induces vasoconstriction in all the 
other abdominal organs innervated by the splanchnic nerves. It is not 
known whether the increased blood flow through the glands by hormone 
action increases the epinephrin output. We have seen that the view that 
painful sensory stimuli, intense emotions, and asphyxia increase the out¬ 
put of epinephrin has been denied by Stewart and Rogoff on the basis of a 
series of careful experiments. It would seem that some of the work of 
Elliott, Cannon, and others, was not adequately controlled. 

Richards and Wood report that stimulation of the depressor nerves 
leads to a decreased output of epinephrin; they interpret this as a true 
reflex inhibition of the action of the secretory nerves. Pende claims that 
section of the splanchnic nerves leads eventually to atrophy of the medulla. 
This is probably erroneous. 

Surgical and traumatic “shock” reduces the epinephrin content of the 
glands to only a fraction of their normal amounts (Corbett). Shock in¬ 
duced by hemorrhage or manipulation of the viscera increases the epi¬ 
nephrin content of the blood coming from the glands up to thirty times the 


THE SUPRARENAL GLANDS 707 

normal (Bedford and Jackson). Stewart, Rogoff and Gibson found that 
massage of the suprarenals increases the secretion of epinephrin. 

Anesthetics, including morphin, decrease the epinephrin content of 
the glands (Graham), presumably through a preliminary increased secre¬ 
tion. But depression of the rate of building up the secretion in the gland 
may also be a factor. The epinephrin content of the glands is also greatly 
decreased in many infectious diseases, especially the acute infections such 
as peritonitis (Elliott, Reich, and Berenegowski, Kindley, and others). 
But there is no evidence that epinephrin deficiency is a factor in the 
debility and prostration of acute infections. Pellegrini states that the 
amount of chromaffin tissue is reduced by starvation. But Jackson, 
McCarrison and others have reported hypertrophy of the adrenals in 
starvation and after vitamin-poor diets. Thyroid feeding is said to induce 
adrenal hypertrophy. 

According to Ott and Scott, and Gley and Quinquad, extracts of pan¬ 
creas, liver, thyroid, thymus, gonads, kidneys, pituitary, parathyroid, etc., 
cause an increased output of epinephrin. Evidently this is a toxic action 
of protein-split products in the tissue extracts acting via the vasomotor 
center and the splanchnic nerves, and possibly directly on the medullary 
cells. It is of no significance in the relation of these organs to the nor¬ 
mal work of the suprarenals. 

Dale and Elliott have suggested that some of the general systemic 
actions of alkaloids like nicotin and pilocarpin, and the anesthetics (mor¬ 
phia, chloroform, and ether) are indirect effects due to the increased out¬ 
put of epinephrin caused by these substances. Strychnin and eserin in¬ 
crease the epinephrin output. Nicotin decreases the output. The reports 
on pilocarpin are contradictory. 

There appear to be no seasonal variations in the epinephrin content of 
the adrenal gland (Seidell and Fenger). 

Pharmacological Actions of Epinephrin.—Knowledge of the details 
of the pharmacological action of epinephrin has increased greatly within 
the last few years, and it is now possible to express nearly all the facts 
in the form of a general law: the peripheral effects of epinephrin are in 
most cases essentially the same as those of the stimulation of the sympa¬ 
thetic visceral efferent nerves to the tissues involved. The peripheral 
action is upon the “myoneural junction” which is a part of the “receptive 
substance” (Langley) of the cell. In sufficient concentration epinephrin 
acts also on the central nervous system. It also acts on peripheral mecha¬ 
nisms in which sympathetic innervation has not yet been demonstrated. 

The following illustrations show some of the applications of this law: 

Blood-vessels.—The very great rise of blood-pressure following the 
intravenous injection of large doses of epinephrin is due largely to a 
peripheral constriction of the blood-vessels, especially of those of the 


708 


ORGANOTHERAPEUTICS 


splanchnic area. The constrictor muscles of the blood-vessels are in¬ 
nervated by the sympathetic (visceral) nervous system. In organs (for 
example, brain) in which the sympathetic vasoconstrictor innervation is but 
slightly developed (or, according to some writers, absent) epinephrin has 
but little (according to some, no) vasoconstricting effect (cf. Wiggers). 

The minimum effective dose of epinephrin always causes a primary 
vasodilatation (Cannon, Hoskins). This appears to be, at least in part, a 
central action, that is, stimulation of the central vasodilator mechanism 
or inhibition of the constrictor mechanism (Hartman). All strengths of 
epinephrin appear to cause dilatation of the arteries in the skeletal muscles. 
This action of epinephrin on the blood capillaries is essentially the same 
(both dilation and constriction) as on the arteries, hut some capillaries 
are refractive to epinephrin, despite their sympathetic innervation 
(Krogh). 

The vasoconstricting action of the drug is seen when it is applied to a 
mucous membrane or to the abraded and bleeding skin; the structures be¬ 
come blanched and hemorrhages from small vessels cease. 

Heart.—Extracts of suprarenal and epinephrin cause a marked accel¬ 
eration and strengthening of the heart beat; the effects are the same as 
those of the stimulation of the accelerators (sympathetic motor nerves). 
The maximum rate reached is the same as the maximum rate after 
stimulation of the accelerators; this rate may he maintained for some time 
by the repeated injections of small doses (Hunt). 

In the intact animal the acceleration of the heart is frequently (almost 
always, if the dose is large) prevented, at least at first, by a simultaneous 
stimulation of the vagus centers; the latter is attributed in part to the 
high blood-pressure, hut there is some direct action of the epinephrin both 
on the vagi centers and on the respiratory centers (Brown, Hice and 
Rock). 

The Coronary Circulation.—Epinephrin contracts the coronary vessels 
in man and the monkey, hut in other mammals (dog, cat, rabbit, ox, sheep, 
pig) it dilates the coronary vessels (Barbour and Prince). These dif¬ 
ferences are probably due to the character of the sympathetic innervation 
of the coronary vessels. 

Alimentary Tract.—The effect of epinephrin on the alimentary tract 
is on the whole the same as that of the sympathetic nerves. When the lat¬ 
ter cause inhibition, epinephrin does also; when the stimulation of the 
sympathetic causes contraction, epinephrin does the same. Thus in the 
rabbit, epinephrin causes relaxation of the entire alimentary tract, with 
the exception of the pyloric, ileocecal, and internal anal sphincters which 
contract under its influence. The action of the sympathetic nerves on 
the alimentary tract varies in different species of animals; the effects of 
epinephrin vary in a corresponding manner. 

But the primary action (be it stimulation or inhibition) of epinephrin 


THE SUPRARENAL GLANDS 


709 


on some parts of the gut depends on the state of tonus of that part at 
the time of application of epinephrin. For example, if the mammalian 
cardia is in strong tonus, epinephrin causes inhibition; if the cardia is a 
feeble tonus, epinephrin causes contraction (Carlson). 

Urinary Bladder. —The same relations hold for the bladder as for the 
alimentary tract; in those animals in which stimulation of the sympathetic 
causes relaxation of the bladder and contractions of the urethra, epinephrin 



Fig. 11.—A, Stimulation Effect of Epinephrin on the Rabbit’s Uterus. (Itagaki.) 

B, Inhibitory Effect of Epinephrin on the Uterus of the Rat. (Itagaki.) 

C, Inhibitory Effect of Epinephrin on the Cat’s Intestine. (Young.) 


does the same; when stimulation of the sympathetic is without effect upon 
the bladder, epinephrin is also without effect. 

Uterus. —The effect of the epinephrin upon the uterus is determined 
by the character of the sympathetic innervation. It, like the stimulation 
of the sympathetic, causes powerful contractions of the pregnant uterus 
and of the non-pregnant uterus in certain animals. In the virgin uterus 
of the cat, however, both epinephrin and stimulation of the sympathetic 
cause relaxation. Dale was able to demonstrate the presence of a sympa- 



710 


ORGAN OTHERAPEUTICS 


thetic inhibitory supply to the uterus of other animals also. After very 
large doses of ergot, which paralyze the motor nerves, stimulation of the 
sympathetic or the administration of epinephrin causes relaxation of the 
uterus in all cases. The conditions are analogous to those which hold for 
certain blood-vessels. 

The action of epinephrin upon the uterus is one of the most delicate 
tests for the drug (Erankel’s test) ; a solution containing one part in 
twenty millions is active. 

Bronchial Muscles. —The effect of the epinephrin upon the bronchial 
muscles is of special interest, since it appears that attacks of bronchial 
asthma in man are temporarily relieved by it. This suggests the presence 
of sympathetic inhibitory nerves to the bronchial muscles, but attempts 
to demonstrate their existence have been unsuccessful. Similarly, efforts 
to demonstrate an action of epinephrin upon the bronchial muscles have 
usually failed. Eppinger and Hess, however, believe that epinephrin 
may, through the stimulation of sympathetic inhibitory nerves, counter¬ 
act the contractions of the bronchial muscles caused by increased vagus 
tonus. Januschke and Poliak found that it relaxed the bronchial muscles 
in muscarin asthma and had some relaxing effect on normal animals. 
In frogs and salamanders epinephrin inhibits the hypertonic lung mus¬ 
culature by peripheral action. In turtles and snakes the central lung 
motor mechanism is inhibited by small doses; larger doses depress the 
lung musculature by peripheral action (Carlson and Luckhardt). 

Action on the Pupil. —The intravenous injection of epinephrin into 
animals causes the same changes in the eye as follow the stimulation 
of the cervical sympathetic nerve, namely, retraction of the nictitating 
membrane and of the eyelids, protrusion of the eyeball, and dilatation of 
the pupil (through stimulation of the dilator muscle). Instillation of 
epinephrin into the eye is far more effective in causing dilatation of the 
pupil when the superior cervical ganglion has been extirpated than it is 
in normal animals (Meltzer and Auer) ; this reaction has been utilized in 
locating the site of injuries to the cervical sympathetic (Cords, Sebileau, 
and Lamaitre). Solutions of epinephrin applied repeatedly to the nor¬ 
mal human eye cause dilatation of the pupil (Schultz and Wessley). 
Slight lesions of the cornea greatly facilitate the reactions; Cords has 
used the reaction to detect erosions and ulcers of the cornea. 

The pupil of the frog’s eye (either in situ or enucleated) dilates upon 
the application of very minute amounts of epinephrin; Meltzer and Auer 
suggested that this reaction might be used for the detection and estima¬ 
tion of this substance. The reaction was elaborated by Ehrmann as a test 
for epinephrin. 

The Kidneys. —According to Cow, epinephrin passes directly into the 
blood of the renal arteries and by its local vasoconstrictor action diminishes 
the rate of urine secretion, thus acting as an important control of kidney 


THE SUPRARENAL GLANDS 


711 


activity. But it is difficult to see how this is possible on the basis of the 
relation of the adrenal veins to the kidney arteries. And in the general 
arterial blood there is not enough epinephrin present to act on the renal 
arteries. 

Metabolism. —Epinephrin has little effect upon nitrogen metabolism 
except in inanition, when it is said to increase protein metabolism. This 
effect is attributed by Eppinger, Ealta and Rudinger to a stimulation 
action upon the thyroid. Recent work by Boothby seems to show that 
epinephrin increases temporarily the basal metabolic rate. Cannon has 
reported that intravenous injections of epinephrin induce temporary elec¬ 
trical changes in the thyroid gland, which he interprets as due to in-* 
creased thyroid activity. But there is no antagonistic action of the thyroid 
glands to epinephrin glycosuria as determined by the reaction of the 
animal after extirpation of these glands (Blum and Mark). Wolfe and 
Thatcher found the nitrogen metabolism normal in a case of Addison’s 
disease. The endogenous metabolism, as represented by creatinin and 
uric acid, was below normal. 

Epinephrin has a marked effect upon the glycogen sugar mobilization 
in the body. This appears to be due to the stimulation of certain sympa¬ 
thetic nerves (Tatum). The epinephrin glycosuria is accompanied and 
caused by a hyperglycemia and a diminution of or disappearance of glyco¬ 
gen from liver and muscle. The degree of glycosuria is largely determined 
by the amount of glycogen in the liver, although some excretion of sugar 
is caused in starving animals. 

Zuelzer, Embden and others have found that when epinephrin is added 
to blood used in perfusing an excised liver, it causes the latter to lib¬ 
erate sugar into the hepatic vein in far greater amounts than when normal 
blood is used. The above facts lead to the conclusion that the action of 
epinephrin in producing glycosuria is due to a setting free or mobiliza¬ 
tion of the sugar stored as glycogen. 

It must be noted, however, that the above effects of large doses of 
epinephrin intravenously on glycogenolysis are, strictly speaking, artefacts. 
There is no evidence that such amounts of epinephrin are under any 
conditions put into the blood by the glands in the intact animal. The 
specific antagonistic action of the suprarenal and the pancreatic secre¬ 
tions on sugar metabolism advanced by Ealta and others has proved to be 
erroneous (Mann and Drips). Epinephrin administration does not af¬ 
fect the oxidation of the sugar in the body (Lusk). Epinephrin de¬ 
ficiency causes no permanent change in carbohydrate tolerance (Crowe and 
Wislocki). The failure of pancreas extirpation to cause diabetes after 
previous adrenalectomy in some species is due to the low blood-pressure 
and the moribund condition of the animal (McGuigan). 

Epinephrin in certain concentrations (intravenously) increases the 
coagulability of the blood (Cannon and Mendenhall). In larger doses the 


712 


ORGANOTHERAPEUTICS 


coagulation is delayed. According to Cannon, adrenalin also acts as a 
stimulant to the skeletal neuromuscular mechanism, and he interprets this 
as due to a direct action of epinephrin on the muscle; but this has recently 
been questioned by Schafer. The improved circulation and the mobiliza¬ 
tion of the blood sugar may be the factor in delaying fatigue after large 
epinephrin injections. Epinephrin induces vasodilatation in the skeletal 
muscles (Hoskins, Gunning, Berry). 

Functions of the Adrenal Cortex. —Concerning the role of the adrenal 
cortex we have a number of theories, but very few facts. Ho internal 
secretion has so far been demonstrated. Whipple has obtained an extract 
from the cortex having a pituitrinlike action on the circulation. The 
abundance of lipoids in the cortical cells has led to the suggestion that 
the cortex elaborates these for the use of distant organs. It has also 
been supposed, without evidence, that the precursors of epinephrin are 
elaborated in the cortex. In the absence of a definite internal secretion 
of the cortex, theories of detoxicating functions have been advanced. 

Cortex Essential to Life. —All the evidence, experimental and clinical, 
to date, points to the cortex rather than the medulla as the organ essential 
to life (Biedl, Scott and others). In nearly complete adrenalectomy only 
the cortical remnants undergo hypertrophy (Crowe and Wislocki). 

The most striking correlation of the adrenal cortex appears to be with 
the gonads. Estrus (male and female), pregnancy, lactation, and gonadec- 
tomy are in some species accompanied by increase in cortical substance. 
Tumors and hyperplasias (hypernephroma) of the cortex may be accom¬ 
panied by precocious sex developments (secondary sex characters) both 
in the male and the female (Jump, Beates and Babcock, Baldwin and 
others). But these relations are not of a direct and compensatory char¬ 
acter. Eor the adrenals fail to maintain sex life after gonadectomy, and 
the gonads fail to maintain life itself after adrenalectomy. 

Extirpation of the Suprarenals. —The removal or destruction of both 
suprarenals leads to death within a few hours or days (Brown-Sequard) ; 
exceptions to this rule .are due to the presence of accessory glands. Biedl 
describes the effects as follows: for one or two days the animals seem to 
be entirely normal; on the second or third day there is loss of appetite; 
afterward apathy and muscular weakness become apparent; the movements 
become stiff and uncertain. Then great prostration follows, the animal 
is unable to rise, and lies extended on its abdomen. There is a marked 
fall of temperature (to 30° C. or under), respiration is labored, the heart 
is irregular and weak; the animal usually dies (in.one to three days) 
in this condition of paralysis. Occasionally there are muscular twitch- 
ings, more rarely convulsions. Gradinescu states that after complete 
adrenalectomy rabbits die within seven hours, dogs in ten, and cats within 
forty-five hours. Removal of one adrenal has no effect. On removal of 
the second adrenal the animal usually lives longer than when both glands 


THE SUPRARENAL GLANDS 


713 


are extirpated in one operation. Elliott reports that complete extirpation 
of the adrenals in the cat leads to death with low blood-pressure, fall of 
temperature and great depression of vasomotor and cardiac accelerator 
nerves. But Hoskins and Wheelon state the vasomotor system and the 
vasomusculature are unimpaired at a time when marked asthenia of 
cardiac and skeletal muscles is in evidence. Hence, there is no evidence 
that the sympathetic system suffers primarily in any degree from adrenal 
extirpation. In cats adrenalectomy reduces the basal metabolism about 
25 per cent (Aub). This reduction sets in within a few hours after the 
operation. But non-lethal injuries (ligation, freezing) are said to induce 
a definite but temporarily increased heat production, and this does not 
occur if the thyroids are removed previous to the adrenal injury (Marine 
and Baumann, Scott). 

Injections of epinephrin do not increase vasomotor irritability (Hos¬ 
kins and Rowley). Complete ligation of the adrenal blood-vessels leads 
in a few hours to a distinct fall of blood-pressure, but this is no evidence 
that this fall is due to lack of epinephrin according to McGuigan and 
Mostrom. 

Bierry and Malloisel and also Porges have reported a condition of 
hypoglycemia after adrenalectomy. But this is probably not specific, for 
any condition that induces a marked general depression is accompanied by 
hypoglycemia (McGuigan). Porges found hypoglycemia in three cases 
of Addison’s disease. The reduced amount of sugar in the blood has been 
held to explain, in part, the most striking symptom following the removal 
of the suprarenals —the asthenia. Favorable results in Addison’s disease 
are reported from the administration of sugar (Pitres and Gautrelet). 
Animals deprived of their suprarenals are easily fatigued. If forced to 
exercise they may die suddenly. But that would probably he true of 
animals equally moribund from other causes. 

Crowe and Wislocki report enlargement of the lymph glands in adrenal 
insufficiency. Loewi and Geltwert state that the blood of cold-blooded 
animals from which the adrenals have been removed is toxic. When 
applied to the heart, the heart stops in diastole, evidently by vagus stimula¬ 
tion, as the toxic action is abolished by atropin. Whipple and Christman 
state that adrenal deficiency leads to impairment of the liver, as deter¬ 
mined by the phenolphthalein test. This is probably an indirect effect of 
impairment of the circulation. 

The questions as to which part of the suprarenal system, the interrenal 
(cortical) or the adrenal (medullary), or both are essential to life, has 
been much debated \ some authors have considered that only the former, 
others that only the latter, is essential to life. All the evidence points 
to the cortex as the essential part, but if there is any truth in Gradinescu’s 
theory of epinephrin control of capillary permeability, it is evident that 
the medulla is of some importance. 


714 


ORGANOTHERAPEUTICS 


Disease of the Suprarenal Glands. —The first important contribution 

to the knowledge of the function of the suprarenals was the classical paper 
of Addison (1855) on the disease which hears his name. The disease is 
characterized by a condition of muscular and cardiac weakness, usually 
with a low blood-pressure, a subnormal temperature, apathy, disturbances 
of the digestive tract (vomiting, diarrhea or constipation, finally asthenia), 
pigmentation of the skin and mucous membranes, and a progressive 
cachexia almost always ending in death. There may be periods of spon¬ 
taneous but temporary improvement. Tieken reports a case of appar¬ 
ently permanent (two years) recovery from Addison’s disease. All the 
features of adrenal disease in man are reproduced by adrenal extirpation 
in animals, except the skin pigmentation. This may be due to the speedy 
fatality of complete adrenalectomy; it evidently requires more time for 
effecting the change in skin pigmentation. 

The typical anatomical change found in the suprarenals in Addison’s 
disease is a tuberculous degeneration. The chromaffine tissue in connec¬ 
tion with the sympathetic nerves, outside of the suprarenal glands, has 
also been found involved in a number of cases; in others the chromaffine 
tissue both in and outside of the suprarenal glands was apparently intact. 
It is practically certain that Addison’s disease is due to impairment of 
the adrenal cortex. 

Absence of epinephrin has been found in a number of cases of Addi¬ 
son’s disease (Oliver and Schafer, Luksch, Ingler and Schmorl). 

Studies of other abnormal conditions of the suprarenal glands in man 
have only been suggestive of possible functions of these organs. It has 
long been known that in many cases of congenital malformations (anen- 
cephalia, hydrocephalus) the suprarenals show a condition of hypoplasia or 
of aplasia. In some of these cases only .the medulla was involved, the cor¬ 
tex being normal. The relations of these conditions, whether casual or not, 
have not been definitely determined. On the other hand, excessive growth 
has been reported in cases of tumors of the suprarenals. 

Hypoplasia of the suprarenals has been met in a few cases of retarded 
sexual development, and in cases of osteomalacia and status lymphaticus. 
On the other hand,, hypernephromas originating from cortical suprarenal 
tissue have, in a number of cases, in infants and young children, been 
associated with sex precocity, and in the case of girls with development 
of male characters—such as masculine hair on the face. 

Hypo-adrenia and Hyperadrenia. —During the last twenty years an 
increasing number of disease symptoms (depression, asthenias, etc.) has 
been referred to a diminished output of epinephrin. This chapter in 
medicine is a serious reflection on the knowledge and common sense of 
the medical profession. There is no evidence that hypo-adrenia (too little 
epinephrin) exists except after denervation of the adrenals, or that if it 
does exist it could produce disease (Stewart). “The literature on hypo- 


THE SUPRARENAL GLANDS 715 

adrenia betrays a profound ignorance of modem suprarenal physiology, 
and a remarkable cavalier attitude toward the canons of logic” (Cohoe). 

Many attempts have been made to correlate certain conditions of high 
blood-pressure. with hypertrophy of the suprarenals, especially of the 
medulla; but it is not certain that the suprarenal changes are primary, 
nor has it been shown that there is an excess of epinephrin in the blood 
(Stewart). 

Control of Experimental Adrenal Deficiency.— Efforts to overcome 
the effects of the removal of the suprarenals in animals have been made 
both by the administration of the gland and its extracts. Neither has so 
far met with success. In no case has life been prolonged for more than 
a few hours after the administration of the gland to animals from whom 
the suprarenals have been removed. Considerable improvement in the 
symptoms (increase of blood-pressure, improved respiration) has fre¬ 
quently been reported from the subcutaneous or intravenous injection of 
extracts of the gland, but the results did not differ from those observed in 
animals near death from poisons and other causes. Feeding adrenal tis¬ 
sue, fresh or dried, may be a failure due to the destruction of the hypo¬ 
thetical cortical hormone in the gut. The only avenue of hope in this 
field seems to be in fractionation of the adrenal cortex for hypodermic 
administration. 

So far, transplantation of the suprarenals has been successful only as 
a preventive measure, that is, it is possible to prevent the characteristic 
effects of the removal of the glands by the previous transplantation of a 
gland (Bush). Apparently, when the effects of the removal of the glands 
have become manifest, it is not possible to delay death by the transplanta¬ 
tion of the glands of other animals. Hoskins reports that rats fed on 
dried adrenal glands for two to nine weeks showed hypertrophy of ovaries 
and testes, but no change in other organs, in growth or in general condition. 

Organotherapeutics in Suprarenal Deficiency in Man —Addisons 
Disease. —Addison’s disease is the only condition in man in which a 
suprarenal insufficiency clearly exists, and most of the interest in the 
organotherapeutic use of the suprarenals centers around it. The results 
are essentially negative. 

Other Conditions of Supposed Suprarenal Insufficiency. —Suprarenal 
glands and epinephrin have been administered in a number of conditions 
in which an insufficiency of the glands had, upon inconclusive evidence, 
been supposed to be present. The results have been inconclusive. 

It has been supposed, for example, that a condition of suprarenal in¬ 
sufficiency exists in many chronic diseases, especially tuberculosis, and the 
administration of the gland, or of epinephrin, recommended accordingly. 
It has also been recommended in neurasthenia associated with low blood- 
pressure. It has found extensive use in the cardiovascular exhaustion of 
acute infectious diseases. In this condition, however, it is used as are 


716 


ORGANOTHERAPEUTICS 


other cardiovascular tonics, that is, it is used as are other drugs, and not 
as an organotherapeutie agent in the usual meaning of the term. 

The suprarenal gland, and especially epinephrin, has been used ex¬ 
tensively in osteomalacia. The views as to the value of this mode of treat¬ 
ment (proposed by Bossi) are conflicting; some report favorable results. 
Novak, for example, reports seven cases treated by subcutaneous injections 
of 0.5 to 1 c.c. of the 1: 1,000 solution. Three were improved; in two 
there was a slight diminution of the bone pains at the beginning; and in 
two there was no effect. 

Attempts to deduce a rational basis for the use of suprarenal in osteo¬ 
malacia have been made from the following facts: There may be some 
antagonistic (or supplementary) relation between the ovaries and the 
suprarenals; the latter hypertrophy when the former are removed or are 
atrophic, and also in pregnancy when parts of the ovary are physiologically 
quiescent. Christofoletti has advanced the hypothesis that in osteomalacia 
there is a hypofunctioning of the chromaffine tissue due to a hypofunction¬ 
ing of the ovaries. As was pointed out above, however, in discussing the 
relation between suprarenals and the sex glands, the cortex seems to be the 
part of the former which is chiefly involved, whereas, in the treatment of 
osteomalacia, a product of the medulla (epinephrin) is usually employed. 
The favorable results which at times seem to follow the use of epinephrin 
in osteomalacia are probably due to other factors. 

Certain writers have drawn analogies between the skin pigmentation, 
the lassitude and the vomiting of pregnancy, and some of the symptoms of 
Addison’s disease, and have treated some cases of vomiting of pregnancy by 
the administration, per os or subcutaneously, of 10 drops of the 1: 1,000 
solution of epinephrin. Distinct benefit has been reported from such 
treatment. 

Adrenal preparations have been used in cases of gastro-intestinal atony, 
in diabetes insipidus, rickets, neurasthenia, myasthenia, and other condi¬ 
tions where there is no evidence of primary adrenal insufficiency. 

Pharmacological Uses. —The suprarenal glands (epinephrin, ad¬ 
renalin) are extensively used as a cardiovascular stimulant, as a local hemo¬ 
static, to delay absorption of local anesthetics, and to relieve asthma. 
Solutions of the active principle (epinephrin or adrenalin) have replaced 
the crude extracts of the glands for this purpose. The use of the drug 
in these cases does not differ from that of other pharmacodynamic agents, 
and its detailed consideration does not properly belong in a chapter on 
Organotherapeutics. The action of the alkaloid, epinephrin, has, however, 
certain peculiarities which may properly be pointed out in this connec¬ 
tion. When applied locally it causes an intense constriction of blood-ves¬ 
sels, and this action largely prevents its absorption; hence, when given by 
the mouth or subcutaneously it produces systemic effects only after very 
large doses. One hundred times as much is said to be required to produce 


THE SUPKAKENAL GLANDS 


717 


an effect when given subcutaneously as when given intravenously. Intra¬ 
muscular injections are much more efficacious than subcutaneous ones. 

Epinephrin also differs from most alkaloids (Straub) in that it does 
not accumulate in the tissues and that it is quickly destroyed in the body; 
it exerts its action only during its passage into the tissues, and, hence, 
its action depends upon the difference in the concentration in the tissues 
and in the concentration in the blood, rather than upon its absolute amount. 
Moreover, its effect does not become less after repeated administration; 
the hundredth injection, for example, causes as great a rise of blood- 
pressure as does the first and subsequent injections. 

The above considerations indicate that the best results, when the drug 
is used as a cardiovascular stimulant, are to be expected from the continu¬ 
ous infusion of a weak solution. This conclusion coincides with clinical 
experience. Although life has undoubtedly been temporarily saved by in¬ 
tramuscular or intravenous injections of comparatively strong solutions 
(4 minims of the 1: 1,000 solution, for example), the best results have 
been obtained by the continuous injection of a solution of 1:50,000 or 
1: 100,000 in normal saline solution. 

Epinephrin is quickly absorbed from the lungs, and Auer and Gates 
suggest its administration by intratracheal sufflation in cases calling for 
a sudden stimulation of the heart. 

The use of this drug as a cardiovascular stimulant has proved useful 
in conditions of cardiac and vasomotor failure under anesthesia (general 
and spinal), in shock and acute hemorrhage, and in cases of poisoning 
(as by chloroform and chloral), although very favorable results have also 
been reported in the low blood-pressure of pneumonia and other acute in¬ 
fectious diseases—especially of children. In diphtheria it is said to 
relieve prostration and asthenia, aside from its effect on blood-pressure. 
Rolleston administered it by the mouth in 10 minim doses of the 1: 1,000 
solution every two to four hours, according to the severity of the attack. 

Laewen and Sievers state that in certain conditions of stoppage of the 
heart the injection of 0.2 c.c. of the 1: 1,000 solution directly into the 
heart is permissible. 

The greatest field of usefulness of epinephrin, however, is as a local 
hemostatic. 

It is used to check epistaxis, and also hemorrhages into the rectum 
(hemorrhoids), bladder (100 c.c. of the 1: 10,000 solution, for example), 
uterus, etc., and to relieve congestion of the conjunctiva and of the mucous 
membrane of the nose (as in rhinitis and hay fever), and of other organs. 

It has been used in postpartum hemorrhage; it not only constricts 
the blood-vessels, but causes a contraction of the muscle fibers of the 
uterus. 

It may be applied in solutions of from 1:1,000 or 1: 20,000, either di¬ 
rectly or on cotton, or as a spray, or in ointments; cavities, such as those 


718 ORGANOTHERAPEUTICS 

of the nose and uterus, may be packed with gauze wet with a 1: 5,000 or 
1: 10,000 solution. 

It has also been administered by the mouth (10 to 20 drops of the 
1: 1,000 solution), and also subcutaneously in gastric and intestinal hemor¬ 
rhages (as in typhoid fever), although some report but little benefit from 
such use. The value of epinephrin in controlling internal hemorrhages 
is doubtful in all cases except where the drug can be applied directly to 
the bleeding surface. 

Epinephrin has been extensively used to enhance the action of local 
anesthetics, such as cocain, novocain, etc. It exerts this action not only 
by delaying the absorption of the anesthetic (by which the danger of 
systemic intoxication is also lessened), but, in the case of some of the 
drugs of this class, it seems to have a direct effect upon the action of the 
anesthetic itself (Esch). On the other hand, it is stated (Frohlich and 
Loewi) that cocain increases the sensitiveness of various organs (blood¬ 
vessels, urinary bladder, eye) to epinephrin (and to direct stimulation 
of the sympathetic nerves), so that a weaker solution of epinephrin suf¬ 
fices to cause constriction of vessels when combined with cocain. Such 
combinations of epinephrin and cocain are useful, not only in cases of 
operation, but in examinations. 

A few drops of epinephrin solution, 1: 1,000, are frequently added to 
Schleich’s solutions for local anesthesia; it is also used in connection 
with the induction of spinal anesthesia. 

Epinephrin has been much used to relieve the attacks of bronchial 
asthma; it is applied locally as a spray (epinephrin 1 part, water 750 
parts, glycerin 250 parts (Zuelzer), aqueous solution, 1:1,000 or 
1: 4,000) ; or as an ointment (30 to 60 drops of the 1: 1,000 solution in 
adeps lanse hydrosus and petrolatum, 1 dram each), by subcutaneous in¬ 
jection, or by rectal suppository (Matthews). 

Preparation and Dosage of Epinephrin. —At present the drug is 
employed almost exclusively in the form of solutions of one of the 
salts, usually the chlorid of epinephrin. The solutions on the market 
are usually 1:1,000 in normal saline solution; they usually contain a 
preservative. They deteriorate rather rapidly on exposure to air and 
light, becoming first reddish and then brown; slightly reddish solu¬ 
tions may be used, but the brown ones should not be used. Many of 
the commercial solutions as found on the market vary greatly in 
strength (Schultz) ; this may be due to deterioration through age, or 
the solutions may not have been made of proper strength originally. 
They should be physiologically standardized, unless a very pure prepara¬ 
tion of the active principle is used. 

The active principle of the medulla is known by a great variety of 
names: adrenalin, adrenin, adrin, suprarenalin, supracapsulin, hemisin, 
suprarenin (both natural and synthetic), epirenin, etc. Most of these 


THE SUPRARENAL GLANDS 719 

names are proprietary. It seems better to use the word epinephrin, pro¬ 
posed by Abel, to designate the active principle. 

Untoward Effects of Epinephrin. —Considering the extent to which 
the drug is used, accidents are very rare. A few deaths have been re¬ 
ported from the injection of the 1: 1,000 solution into veins or into the 
uterus. One milligram injected into a vein has caused alarming symp¬ 
toms; 0.3 milligram injected into the uterine cavity has caused collapse 
for one-half hour. 

The intravenous injection of epinephrin is contra-indicated in organic 
heart lesions, nephritis, and arteriosclerosis. 

A number of cases of necrosis and gangrene of the skin have been re¬ 
ported following the subcutaneous injection; these occurred for the most 
part in the aged. Necrosis of the jaw has also been reported. 

Severe hemorrhage following its local application has been described; 
this is attributed to the use of too strong solutions, which constrict larger 
vessels, so that the surgeon neglects to tie them. 

Its repeated administration in large doses to animals is said to cause 
sclerotic changes in the arteries. The fact has been disputed; if cor¬ 
rect, the sclerosis is probably due to the high blood-pressure. Very large 
doses intravenously are fatal, the symptoms being a primary excitation 
and subsequent depression and failure of the central nervous system. Post¬ 
mortem findings are visceral hemorrhages or pulmonary edema (Vincent). 

Summary 

1. Complete destruction or loss of the adrenal glands is rapidly fatal, 
but why this leads to death is still unknown. The adrenal cortex is the 
part of the organ essential to life. 

2. The adrenal medulla secretes a substance, epinephrin, into the 
blood. In sufficient concentrations this substance has specific and striking 
pharmacological actions on the vascular system, the nervous system, sugar 
mobilization, the blood and the alimentary canal. But the quantity se¬ 
creted under normal conditions is not sufficient to produce any of these 
effects, with the possible exception of a slight action on the heart and 
some action on the blood capillaries in the nature of controlling their 
permeability or secretory activity. Whether in conditions of emotional 
stress, pain and intense muscular and nervous .activity there is enough 
epinephrin secreted, by secretory nerve action or through change in the 
blood flow, to have distinct physiological effects—the “emergency” func¬ 
tion of the medulla—is still an open question. The medullary secretion 
has been isolated chemically (epinephrin) and shown to be a useful 
drug in many conditions (circulatory depression, hemorrhage, asthma, 
etc.) not related to any hypofunction of the gland. Epinephrin is prob¬ 
ably a waste product or an excretion rather than a hormone. 


720 


ORGAN OTHEEAPEUTICS 


3. The only malady in man so far definitely shown to be due to adrenal 
hypofunction is Addison’s disease. Many other conditions, such as acute 
infections, various cachexias, prolonged anesthesia, shock, etc., may lead 
to a decrease in the epinephrin content of the medulla, but there is no 
evidence that this is an important factor in these complications. Tumors 
of the adrenal cortex (hyperfunction?) may be associated with sexual 
precocity, and there are other indications of interrelation of some of the 
specific adrenal and specific gonad functions, but this interrelation is not 
of a compensatory nature, for none of the functions of the gonads can be 
assumed by the adrenals, or vice versa. 

4. Adrenal therapy, fresh gland or extracts, by mouth or injections, 
have so far failed to maintain the life of adrenalectomized animals. And 
it has proved itself of uncertain or no value in Addison s disease. In 
view of these facts no credence can be given to the reports of good results 
from adrenal therapy in disorders (neurasthenia, disorders of pregnancy, 
etc.) where adrenal hypofunction has not even been established. Adrenal 
organotherapy is, therefore, still in the experimental stage. 

5. In view of the fact that the adrenal medulla and its secretion 
(epinephrin) is the part least essential to life, experimental and empirical 
organotherapy of Addisons disease should be made with the cortical 
portion, prepared for safe hypodermic injection. It can be considered 
settled that adrenal feeding is a failure. 


THE HYPOPHYSIS 

Structure of the Hypophysis.—The hypophysis is a very complex 
organ as to structure and possibly in function. The anterior lobe (the 
glandula pituitaria proper) develops from a diverticulum of the pharyngeal 
epithelium and is, therefore, of ectodermal origin. The posterior lobe 
(pars nervosa, or true hypophysis) is a diverticulum from the neural 
tube (floor of the third ventricle). In the adult this lobe appears to consist 
of neurogliar cells together with a few nerve cells, and, in some species, 
of cells and colloid derived from the pars intermedia. The pars intermedia 
is made up of modified lobe cells in intermediate contact with the posterior 
lobe. In some animals these pars intermedia cells penetrate for some di¬ 
stance into the posterior lobe. 

The anterior lobe, true to its epithelial origin, appears to have a 
glandular structure. But the cells making up the organ are not of uniform 
structure and staining reactions. The cells are usually classified on the 
basis of their reactions to stains, such as: (1) chromophile, and (2) chromo¬ 
phobe. The first group is again subdivided into acidophile and basophile 
cells. 

Whether these three groups of cells in the anterior lobe represent three 


THE HYPOPHYSIS 


721 


distinct and separate lines of function or only different physiological states 
of one typo of function is still an open question. The chromophile cells 
contain what appears to be true secretion granules, and these are usually 
most abundant in the region of the cell adjacent to the lymph spaces and 
the blood capillaries. 


ode f g ft 



Fig. 12.—Mesial Sagittal Section through the Pituitary Body of an Adult 
Monkey (semidiagrammatic) . a, optic chiasma; b, third ventricle (infundibu¬ 
lum) ; c, d, extension of pars intermedia round neck of pituitary; e, pars anterior 
seu glandularis; f, intraglandular cleft; g, pars intermedia; h, pars nervosa. 
(Herring.) 

The hypophysis thus resembles the adrenal glands in origin. The 
physiological significance of this juxtaposition or fusion of nervous and 
epithelial structures into one gland remains unknown. Gaskell has ad¬ 
vanced the theory that the hypophysis represents the vestigial remnant of 
the esophagus of our vertebrate ancestors, in whom the alimentary tract 
is supposed to have been placed dorsal to the spinal cord. But the effects 
following disease or removal of the hypophysis seem to show that it is not 
vestigial in function, whatever be the significance of its peculiar origin 
and composition. 

The histological picture of the hypophysis, especially the anterior lobe, 
















722 


ORGANOTHERAPEUTICS 


is by no means constant throughout life. There appears to be an increase 
in the chromophile cells at puberty and during pregnancy, and a gradual 
diminution of them after the fortieth year of life, indicating an adjust¬ 
ment of the organ to metabolic rate and possibly to sex life. 

Gemelli, Cushing and Goetsch report that, in hibernating animals 
during hibernation, the hypophysis decreases in size, and the cells of the 
anterior lobe lose their characteristic staining reactions to acid and basic 
dyes. At the end of hibernation the gland again enlarges, cell division 
is in evidence and the cells regain their normal staining reactions. On the 
basis of these findings they accept the theory of Salmon that the de¬ 
pression of the activity of the hypophysis is the primary factor in caus¬ 
ing hibernation, especially since partial hypophysectomy is said to in¬ 
duce depression, obesity, and somnolence in non-hibernating animals. It 
must be noted, however, that the completely or nearly complete hypopli- 
ysectomized dogs of Aschner, some of which lived over a year, did not 
hibernate. Their appearance did not even suggest the condition of semi- 
hibernating animals. The more recent experiments of Mann and Rasmus¬ 
sen failed to confirm the hibernation changes in the hypophysis described 
by Gemelli, and by Cushing and Goetsch. “There is no basis for the 
theory ascribing the phenomena of hibernation to lack of function of any 
or of all the endocrine glands.” 

According to Fenger, the formation of solid colloid in the pituitary 
gland does not occur during the growth period, but is a phenomena of 
adult life. The solid colloidal material in the clefts of the pars intermedia 
is insoluble in Ringer’s solution and is physiologically inert. 

The hypophysis has a very rich blood supply. According to Dandy 
and Goetsch, the anterior lobe receives the blood supply from eighteen 
or twenty small arteries from the various components of the circle of 
Willis. These vessels immediately break up into numerous large sinusoidal 
channels, in apposition with the gland cells and lined only by endothelium. 
“Hence there are no veins or arteries proper in the anterior lobe sub¬ 
stance.” The pars intermedia derives its blood supply from the vessels 
of the stalk, from the posterior lobe, and from the adjacent brain. The 
posterior lobe is supplied by an artery derived from the internal carotid. 

A clear knowledge of the hypophyseal circulation is necessary for the 
interpretation of the results of surgical interference (experimental and 
clinical) with this organ. From the sympathetic carotid plexus nerve 
fibers pass to the hypophysis, particularly the anterior lobe (Dandy). It 
is not known whether these nerves have vasomotor, secretory, or sensory 
function. 

On the assumption that the colloid of the posterior lobe constitutes the 
internal secretion of this part of the gland and the relation of these colloid 
masses to the cells and fibrous tissue, Herring has advanced the view 
that this secretion is normally discharged into the cerebrospinal fluid of 


THE HYPOPHYSIS 


723 


the third ventricle. The theory is accepted by Cushing and Goetsch, and 
by Cow, and they report the presence in the cerebrospinal fluid of a pressor 
substance identical in character with pituitrin. But the results of Cush¬ 
ing have not been confirmed (Carlson and Martin). There is no de¬ 
monstrable trace of pituitrin in the cerebrospinal fluid of the normal dog. 
Wulzen supports the theory of a direct absorption of the pituitary secre¬ 
tion by the lymph-vessels and blood-vessels. Herring himself has shown 
that in some animals there is no passage of colloid into the hypophyseal 
stalk. And as for the view that the colloid constitutes the important 
secretion, tests on the colloid 
found in the hypophyseal cleft 
show it to be physiologically 
inert, at least on the circulation. 

Accessory Hypophysis.— 

Small nodes of glandular tissue 
apparently identical with the 
anterior lobe are present in 
many animals, including man, 
as the so-called pharyngeal 
hypophysis. If this pharyngeal 
hypophysis actually represents 
part of the original connection of 
the intracranial hypophysis with 
the pharyngeal ectoderm, we 
would expect it to exhibit Same Litter ( right ). The operation waa 
evidence of functional changes performed at eight weeks. (Aschner.) 
synchronously with the anterior - 

lobe. Unfortunately but little attention has so far been given to this by 
clinical and experimental workers. Nodules of glandular tissue inside 
the cranial cavity in the neighborhood of the hypophysis proper have been 
described by Dandy and Goetsch under the name “parahypophysis.” 

The most important steps in the development of the knowledge of the 
functions of the hypophysis were the following: The observation (be¬ 
ginning with Rogowitsch, 1889) that extirpation of the thyroid, the gonads, 
or the pancreas leads to a hypertrophy of the hypophysis; the report of 
Marie (1886) of an association between acromegalia and anatomical 
changes in the hypophysis; the discovery (beginning with Oliver and 
Schafer, 1895) that extracts of the gland have marked effects upon the 
blood-pressure, the heart, and the smooth musculature of the body in gen¬ 
eral, especially the uterus; the report of Frolich (1901) of an apparent 
relation between the hypophysis and the condition known as “dystrophia 
adiposogenitalis”; the report (by several investigators, but especially by 
Paulesco, 1907, Cushing, 1909, and Aschner, 1912) that the total or 
nearly total extirpation of the gland is followed by death or by char- 



Fig. 13.— Twelve-months-old Hypophysec- 
tomised Dog (left) and Control of 





724 


ORGAN OTHERAPEUTICS 


acteristic effects upon growth and development; the relation of the hypoph¬ 
ysis to renal activity (beginning with Schafer, 1906) and to diabetes 
insipidus; the studies on the influence of feeding hypophysis on general 
growth, and on development of the gonads (Schafer, 1909, Goetsch, 1916, 
Robertson, 1916). It should be noted, however, that the reliability of 
much of the above work (experimental and clinical) has been seriously 
challenged, especially by Camus and Roussy. Their work indicates that 
the hypophysis is not an important endocrine organ, the symptoms usually 
ascribed to hypopituitarism being due to injury to the tuber cinereum and 
the base of the midbrain. 

Function of the Posterior Lobe and the Pars Intermedia. —These two 
parts of the gland must at present be considered together, because, though 
differing in structure and origin, they are anatomically so closely inter¬ 
woven that they cannot be separated for experimental purposes. 

Action of the Extract. —Oliver and Schafer found that extracts of 
the entire gland raised the blood-pressure. Howell subsequently showed 
that these effects were due entirely to the posterior lobe. Schafer and 
Herring, Herring, Cushing and Goetsch, Lewis, Miller and Mathews, have 
found that the active principle seems to be formed in the pars intermedia, 
from which it passes into the posterior lobe. It is also possible that the 
presence of the pressor substance in the posterior lobe is due to the pars 
intermedia cells distributed among the neurogliar cells and fibers. In 
adult humans there appears to be no true pars intermedia, yet the posterior 
lobe contains the pressor substance. 

The most marked physiological action of extracts of the posterior lobe 
is to cause a constriction of smooth muscle. The constriction of the 
arteries following the administration of such extracts leads to a marked, 
and, as compared with the effect of epinephrin, long-continued, rise of 
blood-pressure. The extracts also cause dilatation of the frog’s pupils, 
strong contractions of the uterus and of the alimentary tract. 

There is thus some resemblance between the effects of extracts of the 
pituitary and of the adrenal medulla; this is, however, only superficial. 
The effect of epinephrin upon organs containing smooth muscle is gen¬ 
erally the same as that of the stimulation of the sympathetic nerves supply¬ 
ing these organs; when the sympathetic causes inhibition instead of con¬ 
traction, epinephrin does the same. The effects of pituitary extracts are 
entirely independent of the sympathetic nerves ; they are exerted directly 
upon the muscle cells (Dale). The action of pituitary extract is more 
nearly like that of the digitalis series, but the effect on smooth muscle is 
much greater than on the heart muscle. Hence, the effects of the two 
drugs are in many instances different. Thus, the pituitary causes marked 
constriction of the coronary and pulmonary vessels; epinephrin has but 
little effect upon these. Pituitary extract always causes marked contrac¬ 
tion of the uterus, whether this is pregnant or at rest; the effect of 


THE HYPOPHYSIS 


725 


epinephrin depends upon the sympathetic innervation, and so, under some 
circumstances, causes a relaxation. Epinephrin stimulates the endings 
of the sympathetic nerves of the heart, causing an acceleration and aug¬ 
mentation of the heart heat; pituitary extract causes a slowing and at 
first a strengthening of the beat, but this soon gives place to a weaken¬ 
ing. The latter effect is probably due in part to the constriction of the 
coronaries; this is antagonized in the intact animal by the rise of blood- 
pressure, so that the secondary weakening of the beat is not usually 
observed. 

Howell made the interesting observation that a second injection within 
one-half to one hour does not cause a second rise of blood-pressure; it 
may even cause a fall. Later a rise again is observed. This observation 
is of importance in connection with the therapeutic use of the extract. It 
is not a true immunity, according to Dale, but small doses can be in¬ 
jected repeatedly at intervals of ten to fifteen minutes without significant 
failure of their pressor effect (Hoskins and McPeek). The active prin¬ 
ciple is excreted in the urine. 

The rise of blood-pressure following injection of posterior lobe extract 
takes place after removal of the adrenals, and is, therefore, not a secondary 
effect due to increased secretion of epinephrin. 

Krogh has reported experiments intended to show that the “hormones” 
of the posterior lobe (pituitrin) control the tonus of the blood capil¬ 
laries. 

Von Frankl-Hochwart and Frohlich found an increased irritability of 
the automatic motor nerves of the bladder on faradic stimulation. Sim¬ 
ilarly, the irritability of the hypogastric nerves to the uterus was much 
increased. These effects were produced only by the first injection of the 
extract. 

Magnus and Schafer and also Schafer and Herring reported that the 
intravenous, subcutaneous, or intraperitoneal injection of extracts of the 
posterior lobe caused marked and long-continued diuresis and dilatation 
of the kidneys. According to the same authorities administration by the 
mouth also increased the amount of urine secreted, both in animals and 
in man. 

There has been considerable discussion as to whether this diuresis is 
due to a direct action upon the cells of the kidney or is brought about 
indirectly through changes in the circulation. Schafer and Herring and 
also Hoskins and Means support the view that the action is primarily on 
the kidney cells directly, and only secondarily aided by the changes in the 
circulation, while Houghton and Merrill and also King and Stoland con¬ 
clude that it is purely a vascular phenomena, the pituitrin diuresis run¬ 
ning parallel with the vasodilatation in the kidneys. 

The statement of Schafer that the administration of posterior lobe 
extract by mouth induces diuresis has not been substantiated by recent 


726 


ORGANOTHERAPEUTICS 


workers. In fact Orlandi, Konsehegg, Hoppe-Seyler, Fry, Mozfeldt, Rees 
and others report that feeding, hut especially hypodermic injection, of 
posterior lobe extract decreases the urine volume both in normal per¬ 
sons and in various conditions of polyuria, such as diabetes insipidus, 
without influencing the total solids excreted. Injection (hypodermatic) 
of 'posterior lobe extract appears now to be an established therapy for 
temporary control of diabetes insipidus. This may be a drug action rather 
than an endocrine action. But so far as the posterior lobe of the hypoph¬ 
ysis is related to diabetes insipidus, it is lack of the secretion rather 
than the excess of it that leads to the polyuria. When the extract is given 
by mouth or hypodermatically, the absorption is too slow to induce vascu¬ 
lar changes, and, hence, the temporary diuresis seen on intravenous in¬ 
jection does not appear. How pituitrin checks diuresis and reduces the 
urine volume in normal persons and in polyuria is still an open question. 
Rees has reported work indicating that pituitrin slows the absorption of 
water from the intestines. 

Borchardt, Goetsch, Cushing and Jacobson found that injection of 
posterior lobe extract may induce hyperglycemia and glycosuria, analogous 
to the action of epinephrin. It is not yet known whether the temporary 
glycosuria obtained by some observers is secondary to the disturbances in 
circulation, or is an index of a primary and special relation of the posterior 
lobe to carbohydrate metabolism. Falta, Franchini, Guadri, Masi and 
others maintain that the administration of posterior lobe extract does 
not induce hyperglycemia or glycosuria. Intravenous injection of ex¬ 
tracts of fresh pituitary gland, the anterior or the posterior lobes, or the 
implantation of the entire fresh gland into the animal does not produce 
glycosuria in the dog. This is at least true of the quantity of the hypoph¬ 
ysis represented by from two to ten glands of the dog (Carlson and 
Martin). 

Alleged Galactagogue Action of Posterior Lobe Extract. —In 1910, 

it was reported by Ott and Scott, and subsequently confirmed by Schafer 
and Mackenzie, Maxwell and Rothera, and a number of other observers, 
that injection of posterior lobe extract into lactating animals and lactating 
women causes a temporary flow of milk from the nipple. This was first 
thought to he a true “lactagogue” action, and, hence, of great practical 
importance in medicine. But Ott and Scott reported a similar “lacta¬ 
gogue” action from the injection of thymus, pineal gland, and corpus 
luteum extract, and it was soon discovered that on continual administra¬ 
tion of posterior lobe extract there is no increase in the total milk yield 
either in experimental animals or in women. And it has now been 
demonstrated (by Gaines and others) that the apparent lactagogue action 
of hypophysis extract is due to the contraction of the smooth muscle in 
the duct system forcing out any milk already formed in the gland, and 
not a stimulating action on the milk-producing cells. It is another in- 


THE HYPOPHYSIS 727 

stance of the action of posterior lobe substance on smooth muscle and is of 
no practical importance in pediatrics and gynecology. 

Weed and Cushing recently reported that extracts of the posterior 
lobe of the hypophysis increase the rate of production of cerebrospinal fluid 
(choroidorrhea) by stimulating the secretory activity of the choroid plexus. 
But Becht has shown that the apparent increase in the cerebrospinal fluid 
after such injections is due to circulatory and respiratory changes fol¬ 
lowing the pituitrin injection, and not to an increased secretory activity. 
Cow reports that extracts of duodenal mucous membrane stimulate the 
posterior lobe to increased secretion. His experiments are not convincing. 

Posterior lobe extract, intravenously injected, has a direct action on 
the respiratory center, causing usually an increase in depth of the respira¬ 
tory movements, followed by shallow and slow respiration (Nice, Bock 
and Courtright). It decreases the rate of secretion of the saliva (Stoland 
and Lommen). 

Continued daily injections of posterior lobe extract are very deleterious, 
leading to emaciation, depression, fever, tissue changes—especially in 
the liver—vascular disturbances, etc. Harvey reports sclerotic changes 
in the coronary vessels after repeated injection of pituitary extract. This 
is of great practical importance. It is evident that the various posterior 
lobe extracts, so far prepared, do not represent the normal secretion or sub¬ 
stance passed into the blood by the gland , or else these substances are con¬ 
taminated by injurious split products of the cell constituents. 

The specific pressor substance in the posterior lobe and pars inter¬ 
media is in evidence in early fetal life; in cattle it can be demonstrated 
at the eighth week of gestation (McCord). In the pig fetus, only 175 
millimeters in length, the pressor substance is very abundant (Lewis). 
If this substance represents an actual internal secretion, the gland is evi¬ 
dently functioning during intra-uterine development. 

The active principle or principles of the posterior lobe have not been 
isolated, and little is known as to their chemistry. They are dialyzahle, 
are not destroyed by boiling, and are soluble in water and ethyl alcohol 
(Fenger) ; they resist peptic hut not tryptic digestion. They do not 
give the color reactions characteristic of epinephrin, although they seem 
to give certain decomposition products analogous to those of this com¬ 
pound. The colloid masses present in the adult’s posterior lobe and in 
the pars intermedia are physiologically inert (Lewis, Miller, Mathews, 
Both, Fenger). There is no iodin either in the anterior or the posterior 
lobe even after complete thyroidectomy (Wells, Simpson and Hunter), 
but some posterior lobe extracts on the market are reported to contain 
iodin. Belatively large amounts of calcium and phosphorus are present, 
besides traces of arsenic and bromin (Biedl) ; cholin, guanin, histidin, 
and histamin have been reported (England and Kutscher, Aldrich, Abel 
and Nagayama, Jackson and Mills). Koessler and Hawk maintain that 


728 


ORGANOTHERAPEUTICS 


there is no histamin in the fresh posterior lobe Crystalline substances 
showing some of the characteristic activities of posterior lobe extract have 
been isolated by Aldrich, Houssay, and especially by Fiihner; the latter 
investigator was able to isolate four crystalline substances exhibiting physi¬ 
ological activity. These were named collectively, by Euhner, “hypo- 
physin.” 

The commercial preparation, “pituitrin,” is an extract of the posterior 
lobe. One cubic centimeter is said to correspond to 0.1 gram of the fresh 
or to 0.1 gram of the dried gland. “Pituitary liquid” is said to be a 20 
per cent extract of the fresh gland. 

Standardization of Posterior Lobe Extracts. —Roth (1914) found 
that the various commercial preparations of the posterior lobe on the 
market varied greatly in physiological activity, some being fifteen times 
stronger than others. This is a very serious situation, in view of the in¬ 
creased use of this extract, especially in obstetrical practice, and because 
of the serious consequences (such as rupture of the uterus, etc.) that may 
follow the administration of too large a dose. In view of the fact that 
there is no seasonal variation in the activity of the posterior lobe, and 
little or no difference in the activity of the gland from different species 
of animals (cattle, hogs), the actual variations in the strength of prepara¬ 
tions must he due to faulty processes of manufacture. It evidently does 
not suffice to state the strength of the preparation in terms of the percent¬ 
age of fresh or dried gland present. Roth has demonstrated a practical 
method of standardization by comparing the extract (using a guinea 
pig’s uterus as a test object) with a definite dilution of histamin. But 
Abel and Rauiller have recently reported the isolation of a substance 
from the posterior lobe having forty times the action of equal quantities 
of histamin. 

Posterior lobe extract has become a useful drug in labor. It is 
obvious that such standardization of posterior lobe extracts for clinical uses 
would make the substance safer. 

Feeding Experiments with Posterior Lobe. —These have so far 
thrown little or no light on the physiology or possible therapeutic use 
of the organ. Caselli, Sandri and Goetsch report retardation of growth 
in young animals on continued feeding. Aldrich, Lewis and Miller noted 
no effect on growth or health condition of the animals fed. Behrenroth 
obtained indications of increased rate of maturation of the gonads. 
Goetsch states that feeding the dried powdered posterior lobe extract to 
young rats in daily doses of 0.1 gram causes failure to gain in weight, 
increased peristalsis, mild enteritis, and certain nervous manifestations 
such as muscular tremors and weakness of the hind limbs. These effects 
are not produced by smaller doses (0.05 gram per day). These smaller 
doses have no effect on growth, hut seem to retard the development of 
the sex glands. A dose of 0.05 gram dried pituitary per day given to 


THE HYPOPHYSIS 


729 


young rats weighing 25 to 50 grams is equivalent to a daily dose of 150 
to 300 grams dried gland in a person weighing 60 kilograms—a quantity 
far in excess of the total daily protein requirements of the individual. 
It would thus seem that these experiments are far outside the range of 
organotherapeutic possibilities for man. Feeding experiments must be 
made with smaller doses. 

Function of the Anterior Lobe. —Most of our knowledge of the physio¬ 
logical importance of the anterior lobe has been secured by the method 
of extirpation, feeding the gland, transplantation, direct stimulation, and 
from diseases (tumors and cysts) of the organ. 

Alleged Growth-controlling Principle of Anterior Lobe — Tethelin .— 
Apart from the fact that extracts of the anterior lobe, like tissue extracts 
in general, cause, on intravenous injection, a temporary lowering of the 
blood-pressure (Hamburger), nothing of importance has been gained by 
this line of study of the anterior lobe. Robertson isolated a mixture of 
substances, from the anterior lobe, which, according to him, has the same 
stimulating action on growth as the entire gland, and, hence, named by 
him tethelin. But the influence of anterior lobe feeding on growth is still 
an open question. Tethelin contains 1.4 per cent phosphorus, and nitrogen 
in proportion to four atoms for every atom of phosphorus, some of the 
nitrogen being present in amino groups. It probably contains an imid- 
azolyl group, and to this extent may be regarded as related to the 
physiologically active substance of the posterior lobe. But tethelin does 
not possess the characteristic physiological activity of the posterior lobe 
extract, for large doses given intravenously have only a slight depressor 
action on the blood-pressure, and practically no action on the heart, the 
uterus, or the musculature of the alimentary tract. Tethelin has as yet 
no proved therapeutic value . 

Extirpation of Anterior Lobe. —The literature on the effects of partial 
and complete removal of the hypophesis since the first paper by Horsley 
(1886) to the extensive work of Aschner (1912) is as extensive as it is 
contradictory. Part of the conflicting results are due to the difficulties 
of the operation (extensive hemorrhage, injury to the brain, etc.). There 
is no doubt that removal of the gland by the buccal route is, in the hands 
of skilled experimenters, attended with less brain injury than the cranial 
route of Paulesco and Cushing. The most instructive results are those 
reported by Cushing and his coworkers, Sweet and Allen, Aschner, Smith, 
Camus and Roussy. Their studies, viewed in the light of the entire litera¬ 
ture, appear to warrant the following conclusions: 

1. Cutting the stalk of the infundibulum, or removal of as much 
of the posterior lobe and pars intermedia as is possible without too great 
injury to the anterior lobe, has no marked effect on the animal, except 
possiblv some tendency to adiposity due to injury to the base of the brain. 


730 


ORGANOTHERAPEUTICS 


2. Complete or nearly complete removal of the anterior lobe in young 
animals leads to retardation of growth, especially of the skeleton, prevents 
maturation of the gonads, thus causing failure of development of the sec¬ 
ondary sex characters, causes depression, sluggishness and somnolence, 
a tendency to excessive obesity, a lowered rate of metabolism, and possibly 
some increase in the carbohydrate tolerance, hyperplasia of the thyroid, 
thymus, and the cortex of the adrenals; it shortens the span of life. 

3. The anterior lobe appears to he necessary for normal growth and 
development, hut its removal is not fatal. The death of hypophysectomized 
animals, as reported by many workers, within two to five days of the 
operation, with symptoms of extreme depression, is probably due to 
hemorrhage and brain injuries. At any rate it does not appear to he 
due to the loss of the anterior lobe. Complete removal of the posterior 
lobe and pars intermedia is more difficult without injury to the base of 
the brain. 

4. In the adult animal complete or partial removal of the anterior 
lobe may induce a temporary hyperglycemia and glycosuria, excessive 
deposition of fat, progressive atrophy of the gonads and the sex characters, 
and various histological changes in the other endocrine glands. 

5. In most cases partial removal of the hypophysis, or mere operation 
in the region of the hypophysis, induces a temporary diabetes insipidus. 

6. It is, at present, impossible to state what part of the symptoms 
following hypophysectomy is due to brain injuries; what part is due 
to loss or injury of the gland. I have had apparently completely hypoph¬ 
ysectomized dogs showing no demonstrable symptoms. 

Transplantation of the Hypophysis. —In the hands of most observers 
the transplanted hypophysis appears to he quickly absorbed without pro¬ 
ducing any definite effects on the animal. Exner reports a temporary 
increase in growth when several glands were transplanted into young rats. 
Cushing and his pupils state that symptoms of complete or partial 
hypophysectomy are delayed or diminished, at least for a time, by trans¬ 
planting a part of the gland. The same author reports favorable results, 
at least temporarily, from transplantation of a child’s hypophysis into 
the brain of a patient suffering from hypopituitarism due to a hypo¬ 
physeal cyst. There is nothing in the literature to indicate that a trans¬ 
planted hypophysis becomes permanently functional in the host. Nor 
has it as yet been possible to produce any of the symptoms of acromegaly 
by implanting excessive amounts of hypophysis into animals. 

Direct Stimulation of the Hypophysis. —-Weed, Cushing and Jacobson 
report that direct stimulation of the hypophysis, mechanical or electrical, 
induces a temporary glycosuria. This is said to occur even after section 
of the splanchnic nerves or the spinal cord below the level of the phrenic 
nuclei, showing that it is not due to brain and splanchnic stimulation. 


THE HYPOPHYSIS 731 

Cushing interprets the results as due to an excessive liberation of posterior 
lobe secretion into the blood by the stimulation of the gland. Using more 
accurate methods, Keeton and Becht showed that while direct stimula¬ 
tion of the. gland induces hyperglycemia and glycosuria, this does not 
occur in animals with section of the spinal cord or the splanchnic nerves 
a fact which argues against the liberation of an hypophysis hormone 
which increases directly the glycogenolysis in the liver. The question 
of the possibility of inducing excessive hypophysis activity by direct 
mechanical stimulation of the gland is of great practical importance in 
cases of head and brain injuries and brain tumors in man. 

Alleged Secretory Nerves to the Hypophysis.— This question is as 
yet an open one, owing in part to the fact that we have no certain test of 
hypophyseal hyperactivity in crucial experimental stimulations lasting, 
at the most, a few hours. Weed, Cushing and Jacobson, and Shamoff 
reported that stimulation of the cervical sympathetic nerve, and especially 
the superior cervical ganglion in rabbits, induces glycosuria. This they 
interpret as due to the stimulation of secretory nerve fibers passing from 
the cervical sympathetic to the posterior lobe. Although using more 
accurate methods, Kabens and Lifschitz failed to confirm Cushing’s 
results. 

Effects of Feeding and of Injection of Anterior Lobe Extract, Ex¬ 
perimental. —Cushing, Sandri, Aldrich, Grail, Wulzen and Maxwell, and 
Lewis and Miller, and others report impairment of growth or loss of 
weight on feeding or injection of anterior lobe substance. This may be 
due to excessive doses used. Schafer, on the other hand, reports little 
or no effect on growth from anterior lobe administration. Robertson, 
working on mice, and feeding fresh anterior lobe (0.125 gram per day), 
reports that when the feeding is begun at the fourth week of life there is 
first a retardation and later on an acceleration of growth, so that the 
hyphophysis-fed mice finally attain, and may even surpass, the size of the 
control animals. However, the pituitary-fed animals are on the whole 
smaller than the controls, although they weigh more and appear to be 
more compactly built. There is certainly nothing in the data presented 
by Robertson that indicates an approach to acromegalia in the pituitary- 
fed mice. Robertson also found that feeding the substance tethelin (iso¬ 
lated from the anterior lobe) produced essentially the same effect as feed¬ 
ing the entire lobe tissue. 

In another report Robertson and Burnett state that injection of an 
emulsion of the anterior lobe into tumors (carcinomata) in mice increases 
the rate of the tumor growth without increasing the tendency to metastases. 
Wulzen reports further that the growth of planarian worms is accelerated 
by a diet of anterior lobe and pars intermedia, provided the feeding is 
begun early in life. Any part of the hypophysis increases the rate of 
fission in these lowly forms. Robertson also states that hypodermatic 


732 


ORGANOTHERAPEUTICS 


injections of tethelin stimulate the action of tissue repair, as expressed 
in the replacement of tissue lost during a preceding period of starvation 
or in the healing of granulating wounds. 

The extensive studies of Goetsch on white rats seemed to demonstrate 
that continued feeding of anterior lobe to young animals accelerates body 
growth and hastens sexual maturity, while similar feeding of posterior 
lobe retards both growth and sexual development. When the anterior 
lobe is fed to adult rats, sexual activity, as indicated by the number of 
pregnancies, is augmented. Goetsch’s work appears convincing, but it 
seems difficult to reconcile his 100 per cent positive results with the nega¬ 
tive findings of practically all other investigators (cf. Krass). Robert¬ 
son and Wulzen give the impression that the anterior lobe feeding did 
exert some stimulating action on the sex function in some animals (mice, 
chickens). 

According to Pearl and Surface injection of anterior lobe substance 
or extract into the peritoneal cavity of fowls does not activate the com¬ 
pletely resting ovary. Feeding the same to egg-laying hens does not 
accelerate egg production. Feeding the anterior lobe substance to young 
pullets does not bring about an earlier activation of the ovary. Feeding 
anterior lobe substance or desiccated corpus luteum to young pullets 
retards growth, but has no effect on the rate of development of sexual 
maturity. Clark, on the other hand, reports that feeding the anterior 
lobe substance to hens increases egg production as well as the fecundity 
of the egg. This effect becomes evident after three or four days’ feed¬ 
ing, and persists a few days after ceasing the feeding. Clark’s experi¬ 
ments are criticized by Pidot. Uhlenhuth reports some excess growth 
of salamander larvae fed on the anterior lobe. 

The present state of the literature on pituitary feeding of normal 
experimental animals seems to admit of the following conclusions: 

1. Feeding anterior lobe may slightly accelerate the growth of young 
animals, but there is no evidence that the final stature is greater than 
that of the control animals. Hence, there is no evidence of experimental 
acromegalia or gigantism, at least in mammals. 

2. Anterior lobe feeding is reported to accelerate sexual maturation 
in the young and stimulate sexual activity in the adult animal, while the 
posterior lobe has the opposite action. But more work is needed before 
this thesis is established. In view of the conflicting literature, we cannot 
refrain from expressing the fear that some authors may have reported 
what they thought they ought to have found, rather than impartial objec¬ 
tive results. Hypogenitalism and retarded growth are ascribed by so many 
clinicians to impairment or destruction of the hypophysis; hence, that 
hypophyseal organotherapy ought to produce the opposite results appears 
so reasonable as to lull scientific critique. 


THE HYPOPHYSIS 


733 


Functional Disorders of the Hypophysis; Alleged Hyperpituitarism. 

—For some time after the report of a relation between acromegalia and 
the hypophysis there was much discussion as to whether the disease was 
due to a condition of hyperactivity, of hypo-activity, or of a perverted 
activity of the gland. The theory has also been advanced that the pitu¬ 
itary changes in acromegalia are secondary to the bone growths and the 
general disorders of the body. It is now generally held, though not proved, 
that the former is due to hyperplasia and increased activity of the anterior 
lobe—at least in the early stages of the disease. The primary pathological 
condition in acromegalia is usually one of simple hyperplasia (adenoma) 
of the anterior lobe—especially an increase in the number of chromophile 
cells (Lewis, Csepai, Kahlmeter and others). It frequently shows indi¬ 
cations of malignancy. At the same time there seems to be at least a 
functional involvement of the posterior lobe„ In late stages there may 
be an extensive degeneration of the gland; and this has an important 
bearing upon the possible therapeutic use of the gland in acromegalia. 
The amelioration which may follow the removal of part of the hypophysis 
in acromegalia (Hochenegg) affords additional proof that the condition 
is one of hyperpituitarism. At the same time it must be admitted that 
the precise relation of hypophyseal activity to acromegalia and gigantism 
has not yet been established. Cognetto advances the following argument 
against the generally accepted hyperpituitary theory. 

1. Cases of acromegalia have been observed without tumors of the 
hypophysis. 

2. Adenomas composed entirely of chromophilic cells of the anterior 
lobe have been found associated with acromegalia. 

3. Adenomas of the hypophysis composed entirely of chromophilic 
cells, but without acromegalia, have also been described. 4 

Two sets of symptoms are caused by hypertrophy of the hypophysis; 
(1) those which appear to be due to the specific hyperactivity of the 
gland; (2) those produced by the pressure of a tumor in this region. 
The specific effects supposed to be due to hyperactivity, which may throw 
some light upon the normal function of the gland, are marked and chaiac- 
teristic changes in the features and in the extremities, due partly to 
the growth of the soft tissues, partly to an enlargement of parts of the 
bones of the head, feet and hands. 

Keith has studied in detail the changes in the skull in acromegalia, 
and the manner in which they are induced. He concludes that an internal 
secretion of the hypophysis sensitizes tissues so that they respond to the 
natural stimuli of growth (mechanical acti vity and muscular movement) 

4 In some cases there are changes in the cranial bones without acromegalia.- 
Editor. 






734 


OKGAN OT HER APE UTICS 


with increased energy. The enlargement of the extremities is due largely 
to connective-tissue growth. 

Among other symptoms of acromegalia are lassitude, muscle pains, 
apathy, and disturbances (depression) in sexual activity; there may be 
amenorrhea in women and frequently impotence in men, but excessive 
sexual activity may also be present. Vasomotor changes in the skin are 
frequent. Polyuria, with or without glycosuria, is not uncommon. 

Borchardt found glycosuria in 40.3 per cent of 176 cases. In later 
stages, where the hyperactivity of the gland is being replaced by hypo- 
activity, there is, according to Goetsch, Cushing and Jacobson, not only no 
glycosuria, but an increased tolerance for carbohydrates; but these authors 
consider both the glycosuria (lowered carbohydrate assimilation) and the 
subsequent increased carbohydrate tolerance to be due to hyperactivity and 
hypo-activity, respectively, of the posterior lobe. 

The literature on the condition of metabolism in acromegalia is con¬ 
flicting, but in the early stages there appears to be a definite retention of 
calcium, magnesium, and phosphorus (Bergheim, Stewart, and Ilawk) 
probably in consequence of the new bone growth. Part of the contra¬ 
dictory results are probably due to the fact that only the early stages of 
the disease are associated with hyperactivity of the anterior lobe, and 
this is followed later by destructive changes in the gland and hypopitu¬ 
itarism (Tamburini, Schafer). Since pure hyperpituitarism (experi¬ 
mental hypophysectomy) seems to be followed by some lowering of the 
rate of metabolism, we would expect an increased rate of metabolism in 
acromegalia, if it is due primarily to hyperactivity of the hypophysis. 

The studies of acromegalia show that there is a. close relationship 
between the hypophysis and growth, especially of connective tissue, car¬ 
tilage and bone, and also between this gland and the activity of the sex 
glands, thus supporting some of the experimental results on the hypophysis. 

The relation between the hypophysis and growth has been further 
emphasized by studies on gigantism; in this condition also hyperplastic 
conditions of the hypophysis are frequently found. In many of these 
cases, however, other glands of internal secretion are so greatly involved 
that it is impossible to determine whether the changes in the hypophysis 
are primary or secondary. The other glands chiefly involved are the 
sex glands, which may be atrophic, and the thyroid. In certain cases of 
dwarfism, on the other hand, the anterior lobe of the hypophysis is said 
to be destroyed (Aschner). 

It is interesting to note in this connection that favorable results in 
precocious gigantism have been reported from the administration of 
ovary, and that the changes in the hypophysis in animals following cas¬ 
tration may be partly prevented by the injection of testicular extracts. 
Hatai reports, however, that in the albino rat there is no hyperplasia of 
the hypophysis following spaying, while castration of the male induces 


THE HYPOPHYSIS 735 

the hyperplasia. Tandler suggests that the special growth features of 
eunuchism may be due to the hyperplasia of the thyroid that follows 
castration. But in the rat and the guinea pig the changes induced in 
the hypophysis by gonadectomy appear to be of the nature of atrophy 
or degeneration (Addison, Moore). 

A condition of hyperpituitarism is believed to exist, as has already 
been indicated, after castration, which usually leads to some enlarge¬ 
ment of the hypophysis, and also during pregnancy, when some of the 
functions of the ovaries are in abeyance. There are not only charac- 



Fig. 14. —Adult Dogs, Male and Female, Some Months after Removal of the 
Greater Part of the Pituitary Body. In each case a control of the same litter 
is shown on the right of the operated animal. The tendency to adiposity is marked 
in both sexes. (Cushing’s The Pituitary Body. J. B. Lippincott Co.) 


teristic changes in the hypophysis during pregnancy, as indicated by 
increase in size and by histological changes, but certain general symptoms 
of pregnancy (enlargement of the hands, changes in the facies suggestive 
of acromegalia) are considered to be due to the hyperpituitarism. Some 
of these changes may persist after termination of the pregnancy. 

Removal of the thyroid also leads to hypertrophy of the hypophysis 
(Rogowitsch, Levingston) ; the latter is also found in many cases of 
hyperthyroidism in man. Symptoms referable to the hypophysis have 
been reported after thyroidectomy. 

Functional Disorders of the Hypophysis; Alleged Hypopituitarism.— 
The condition of hypopituitarism is of interest in connection with the 
organotherapeutic use of the hypophysis. 



736 


ORGANOTHERAPEUTICS 


A condition of hypopituitarism is assumed to exist in the disease 
“dystrophia adiposogenitalis,” first described by Frohlich in 1901. In 
this condition there are usually hypophyseal tumors or cysts of a destruc¬ 
tive character, combined with obesity, a hypoplastic condition of the sex 
glands, and retarded growth or infantilism. Some of these symptoms— 
notably the obesity—occur also in the later stages of acromegalia. 

The view that this condition is really due to a primary involvement 
(hypofunctioning) of the hypophysis is largely based upon experiments 
upon animals (Cushing, Aschner) in which the hypophysis was partially 
removed, as detailed above, and on the effects of clinical organotherapy 
(Beck, Engelbach, Tierney, Timme, and others). 



Fig. 15.—Tracing Showing the Effect of Intravenous Injection of Extract of 
the Posterior Lobe of the Hypophysis on the Blood-pressure. (Schafer.) 


Cushing and his coworkers first believed that the above results were 
due to removal of part of the anterior lobe; later they suggested that 
some of them (the adiposity and increased carbohydrate tolerance) are 
chiefly due to removal or injury of the posterior lobe. Bell thinks that 
the hypophysis acts as a single gland. Beck assumes specific deficiency 
symptoms both of the anterior lobe, namely (1) retarded growth, (2) 
obesity, (3) infantilism, (4) hypothermia, (5) cachexia, and the posterior 
lobe (1) hypotension, (2) increased sugar tolerance, (3) low basal metabo¬ 
lism, (4) asthenia. Engelbach assumes a type of adiposity specific for 
posterior lobe deficiency. Tidy and others assume that only posterior lobe 
deficiency induces diabetes insipidus. 

It must be admitted, however, that it is not possible to state with 
certainty, in cases of clinical hypopituitarism, which symptoms are due 
to lack of anterior lobe, and which are due to lack of posterior lobe, or 
whether any of them are primarily related to hypophyseal deficiency. 
When the cysts or neoplasms become sufficiently large, it is probable that 



THE HYPOPHYSIS 


737 

the activity of the entire gland is depressed (pressure atrophy) irrespective 
of the part of the gland giving rise to the tumor. The difficulty in the way 
of hypophysis organotherapy is further increased by the fact that many 
of the clinical symptoms of hypopituitarism may arise from dystrophy 
of other glands of internal secretion. Thus impairment of growth and 
dwarfism and retardation of gonad maturation may be due to thyroid 
deficiency; sexual infantilism to primary impairment of the gonad; abnor¬ 
malities in carbohydrate tolerance to disorders of pancreas and adrenals ; 
and lowered metabolism and body temperature to a great number of 
causes. Cushing, Falta, Beck, Engelbach and others thus recognize a 
distinct group of cases with hypophysis involvement but showing at the 
same time signs of pluriglandular dystrophy. The organotherapy of this 
group is necessarily complicated, and is at present purely experimental. 

Summary 

Experimental work and clinical observations seem to show that the 
hypophysis is an organ essential to normal life, the removal of which 
may lead in a short time'to death, the partial removal or disease of which 
may lead to a condition of retarded growth or infantilism, to obesity, to 
atrophy of the sex glands, and other disturbances of nutrition; hyper¬ 
activity of the anterior lobe (in acromegalia and gigantism) may lead to 
accelerated and abnormal bone growth, and ultimately to atrophy of the 
sex glands. Nothing is known as to the nature of the action of this part 
of the hypophysis. 

The posterior lobe and pars intermedia contain a substance or sub¬ 
stances having marked effects upon plain muscle, especially that of blood¬ 
vessels and the uterus, and upon the kidney; while it thus has important 
pharmacodynamic actions, its role in the normal animal is obscure, since 
it is not certain that this substance is given off by the gland to the body 
fluids. 

Therapeutic Uses of the Anterior Lobe. —If we assume that the 
anterior lobe secretes a hormone and if the hormone is absorbed in active 
form from the alimentary tract, thus permitting administration per os, or 
when it is prepared in sufficient purity to permit of repeated intravenous, 
intramuscular or hypodermatic injections without untoward symptoms, 
one might hope for favorable results from anterior lobe therapy in all 
diseases due, in whole or in part, to impaired functions of the hypophysis 
(hypophyseal dystrophy, infantilism, amenorrhea, impotency, or impaired 
growth traceable to the hypophysis). The results of clinical use of the 
hypophyseal preparations have so far not come up to this expectation. 
In fact, it has not yet been shown that the effects of partial or complete 
hypophysectomy in experimental animals can be essentially and per¬ 
manently counteracted by hypophyseal organotherapy. The past failure 


738 


OEGANOTHERAPEUTICS 


may be due in part to using the entire gland, rather than the anterior 
lobe, as there is some evidence that posterior lobe substance counteracts 
the effects of the anterior lobe substance in some directions. Recent 
clinical reports record some cases of supposed hypopituitarism in which 
feeding hypophysis, or hypophysis combined with thyroid, seemed to 
improve some of the symptoms (adiposity, general aplasia, somnolence, 
etc.), while other cases showed no improvement. If the diagnosis is cor¬ 
rect it is difficult to explain such discordant results. We must be par¬ 
ticularly careful in cases of delayed adolescence , for here any therapy 
persisted in long enough may seem to be effective, although there may be 
no causal connection between the therapy and the change in the patient. 
That thyroid feeding reduces adiposity is well established; but what light 



Fig. 16.—Tracing Showing the Action on an Isolated Cornu of Rat’s Uterus 
Suspended in Locke’s Solution of the Addition of Extract of Posterior Lobe 
of Ox Pituitary to the Solution. (Itagaki.) 


does that throw on hypopituitarism ? In the present unsettled state of our 
knowledge we must be guided by the following principles: 

1. Diagnosis of hypopituitarism is in no case certain. 

2. Feeding hypophysis has so far failed to control the symptoms of 
certain (experimental) hypopituitarism. 

3. Empirical organotherapy in supposed hypopituitarism is justified, 
but when pluriglandular mixtures are used we are merely treating a 
disease of unknown origin with a remedy of unknown composition. 

The literature shows that, besides the above, hypophysis therapy has 
been tried with varying results in amenorrhea, menorrhagia, asthma, 
hemoptysis, insomnia, angina pectoris, osteomalacia, rachitis, rheumatic 
and gonorrheal arthritis, periostitis, tetany, epilepsy, dementia prsecox, 



THE HYPOPHYSIS 


739 


sterility, impotency, exophthalmic goiter, pneumonia, diphtheria, typhoid, 
hay fever. 

Therapeutic Uses of Extracts of Posterior Lobe (Pituitrin). —Ex¬ 
tracts of the posterior lobe are used chiefly for their effects upon plain 
muscle, that of the uterus, the gut, and blood-vessels, and for the control 
of the polyuria of diabetes insipidus. 

Many recent writers have reported very favorable results from the 
use of such extracts in uterine hemorrhage. The use of pituitrin in 
uterine atony, and in postpartum hemorrhage and in other forms is now 
well established. 

Several writers have advocated the use of pituitary extracts to increase 



Fig. 17. —Tracing Showing the Contraction of 
Musculature of the Mammary Gland Duct 
System of the Goat on Intravenous Injection 
of Pituitrin. The air inflated gland is con¬ 
nected with manometer by cannula in teat. The 
air pressure in the gland before injection of 
pituitrin is 8 centimeters chloroform. Time, 10 
seconds. (Gaines.) 


the blood-pressure in shock and in various infectious diseases (pneumonia, 
diphtheria, typhoid, etc.), claiming that it has the advantage over 
epinephrin of a much more 
lasting effect. But such 
therapy has proved of no 
practical value. Reese and 
others have reported good 
results from pituitary ex¬ 
tract in asthma. This is 
probably an error except in 
the so-called “cardiac” 
asthma due to impaired cir¬ 
culation. In true bronchial 
asthma pituitrin not only 
has no effect, but may be 
harmful ( Koessler). 

Wiggers considers that it is the only drug which meets the indica¬ 
tions for a hemostatic in pulmonary hemorrhage, since it raises the blood- 
pressure by peripheral action (which constricts the bleeding points and at 
the same time prevents anemia of the brain) and causes a weakening of 
the heart, which prevents a rise of pressure in the pulmonary vessels. 

Bell and others recommended it in intestinal paresis after abdominal 
operations. It is said to act more powerfully on the paretic than on the 
normal intestine. 5 

Klotz considers it especially valuable in peritonitis, where it not only 
increases the blood-pressure, but stimulates peristalsis. 

The drug has been injected subcutaneously or intramuscularly in doses 
of 1 to 3 c.c. of the aqueous extract, 1 c,c. corresponding to 0.1 or 0.2 
gram of the fresh gland (posterior lobe), or intravenously in doses of 1 to 
2 c.c. diluted with 20 c.c. normal saline solution. There is danger of 
local necrosis when injections of strong solutions are made subcutaneously. 


6 It is also valuable in the tympanites of pneumonia and other infections. 

Editor. 






740 


ORGANOTHERAPEUTICS 


It has also been given by the month in doses corresponding to 0.2 gram 
to 0.8 gram of the fresh gland, or 1 to 3 grams of the dried gland (pos¬ 
terior lobe). 

The drug is contra-indicated in all conditions of high blood-pressure. 

Although serious untoward results from use of pituitrin do not seem 
to have been reported, except such accidents as uterine rupture from ad¬ 
ministration of pituitrin in labor before dilation of the os, it should be 
remembered that Harvey has produced sclerotic changes in the coronary 
vessels of animals; Crowe has seen loss of weight and marked changes 
in the liver from repeated injections; Thaon reports pathological changes 
in the kidney after prolonged use of large doses; and Franchini has 
observed intestinal ulceration and hemorrhage. 

General Summary 

While specific hypophyseal organotherapy is still in the experimental 
stage, our present knowledge appears to warrant the following: 

1. Administration (per os) of anterior lobe in all cases of supposed 
hypopituitarism. 

2. Possible value of anterior lobe substance (per os) as a stimulant 
to general growth and repair processes. 

3. The use of posterior lobe extract (subcutaneously) as a stimulant 
to smooth muscle (uterus, alimentary tract, cardiovascular system) and 
as an antidiuretic in diabetes insipidus. 

4. Physicians should insist (1) that posterior lobe extract (pituitrin) 
is physiologically standardized by Roth’s or similar methods; (2) and that 
anterior lobe extract be not prepared from the glands of old animals, as 
there are indications of gradual atrophy of the gland in old age. 

THE OVARIES 

Anatomy. —The ovaries of the sexually mature mammalian female 
contain the following tissues: 

1. Ova in varying stages of maturation. 

2. Follicular epithelium and liquor folliculi. 

3. Corpora lutea, or yellow bodies. 

In the ovaries of some species (including man), a fourth element, in¬ 
terstitial cells similar to those of the testes, has been described, but 
these do not form such a distinct element of the ovaries and are more 
readily destroyed by the X-ray than are the cells of Leydig in the testes. 
The ovarian interstitial cells are said to increase during pregnancy, and 
undergo retrogression during hibernation. 


THE OVARIES 


741 


The corpora lutea are not present in the ovary before puberty. This 
particular element can, therefore, assume no role in the development 
of the anatomical and physiological characters peculiar to the female sex. 

Influences of Congenital Absence, Atrophy and Extirpation of 
Ovaries.—If the ovaries are removed in the young female the development 
of all the secondary sex characters is arrested. The uterus, fallopian 
tubes, mammary glands, and the external genitalia remain infantile. 
Heat or rut, and, in the primates, menstruation do not occur. It is 


II. 


III. 


- Heat-changes in the sexual organs combined with sexual desire. 

'*—* Heat-changes in the sexual organs, 
o * Ovulation. 

-mrTflirmUtw = Growth processes in the uterus; the descending branch represents the decline of growth. 

* * Curve of growth and degeneration of the corpus luteum. 

■ ■ “ Resting condition of the uterus. 

— ■ ■ * Hemorrhages taking place at various periods of the sexual cycle. 


Groortk of <TorA Zict. 


> —■ Uinvcit of Co-rfk ■Lu.t. Doc/ino y Cotfi iut 

ofBooiclu*. 7)»9f ofUttru* 




_ 

Infernal Premenstrual Briod Menstruation PostmenSlr. 

& Internal 


I 


30 


Prooejt.Oest. Metoe strum. 


Anoestrum 




First Circle 


Second Circle 


Fig. 18. — Diagrammatic Representation of the Sexual Cycle. I. In the guinea 
pig. II. In apes and women. III. In the dog. (L. Loeb.) 


claimed that there is a tendency to development of some of the male 
phvsical and mental characteristics. The metabolism is lowered, and in 
some individuals there is a tendency to adiposity, just as in the castrated 
male. Stotzenhurg reports that complete ovariotomy in the very young 
rat accelerates the rate of growth, at least during the first year. Spaying 
seems to induce less change in other endocrine glands than castration, and, 
strange to say, in some cases the changes are of the opposite character. 
Ovariotomy in the rat leads to decrease in the size of the adrenals, while 
castration causes adrenal hypertrophy. In the domesticated white rat 
(normal) the adrenals and the hypophysis are larger than m the male rat 
(Hatai). The significance of this is not apparent. Ovariotomy m early 





























742 


ORGAN OTHERAPEUTICS 


pregnancy does not influence the cause of the pregnancy or the subse¬ 
quent lactation. But in mice the incidence of mammary gland cancers is 
reduced by ovariotomy, and spaying retards the postpartum involution 
of the uterus. Moore reports that, in the guinea pig, spaying of the 
young animal leads to decreased growth of the hypophysis, the adrenals 
and the spleen, and a slight increase in the thyroid. 

Ovariotomy in the adult and sexually mature female leads to atrophy 
of the anatomical sex characters of the female, suppression of all sex 
functions and most sex behaviors and, in women, to some of the mental 
and physical symptoms of the natural menopause, such as nervous and 
circulatory disorders. The persistence of menstruation in women after 
supposedly complete surgical ovariotomy is obviously due to ovarian 
remnants. This is all the more evident since the clinical literature con¬ 
tains instances of pregnancy occurring after complete ovariotomy, which, 
of course, would otherwise he absolutely impossible. In adult bitches 
ovariotomy leads to a heightened excitability of the sympathetic nervous 
system (Hoskins and Wheelon) ; this may be the condition that causes 
the nervous and circulatory disturbances of the artificial menopause in 
women. 

Ovarian Transplantation — Experimental.— In all species so far tried 
the ovaries may be successfully removed from their normal position to 
other parts of the body and continue to maintain their normal functions 
for considerable periods. Transplantation from one individual to another 
of the same species appears to yield only a temporary success, although 
Steinach and Sand report grafting of ovaries into castrated males, and 
testes into spayed female guinea pigs, the transplants living and func¬ 
tioning long enough to develop female behavior in the original males and 
male behavior in the original females. Marshall and Jolly, working on 
rats, found that the transplanted ovarian tissue exhibited all the his¬ 
tological features of normal ovarian tissue, except that the germinal 
epithelium was invariably absorbed after a short time. In some cases 
other degenerative changes took place. The stroma might remain normal, 
while all the follicles had disappeared, or the greater part of the graft 
might be composed of luteal tissue alone. A point of great importance, 
noted by these investigators, is that the ovarian transplant undergoes 
the same cyclic changes as the normal ovaries. In animals killed shortly 
before the breeding season, large follicles were found in the graft, while 
a little later corpora lutea were present, showing that ovulation had 
occurred in the transplant. This has recently been confirmed by Moore 
on rats and guinea pigs. Moore has also succeeded in grafting ovaries into 
normal males having intact testes. The ovarian graft in the male becomes 
vascularized, grows and undergoes the normal cyclic changes. In one 
case a homoplastic ovarian graft was found healthy after fourteen months. 
The longest time noted for a heterotransplanted ovary was six months. 


THE OVARIES 


743 

Halban reports successful ovarian transplantation in experiments upon 
monkeys. 

All workers in this field agree on the main points. The ovarian trans¬ 
plant, as long as it lives, maintains all the hormone functions of the 
ovaries in their normal position. These functions are, therefore, internal 
secretion processes, that is, primarily humoral, not nervous reflexes. 

Clinical. Ovarian transplantation, homotransplantation and hetero- 
transplantation in women has been resorted to extensively in recent vears, 
mainly to control the artificial menopause symptoms due to ovariotomv 
or to atrophied or diseased ovaries (Morris, Glass, Dudley, Kramer, 
Tuffier, Martin, and others). Clinical results have not been as uniformly 
successful as those on experimental animals, probably for these reasons: 
(1) In many instances the ovarian graft was not normal to start with 
(infection, etc.). (2) In other cases the state of health and nutritive 
condition of the women receiving the graft were below par—and this 
militated against a successful “take.” (3) Many surgeons have made the 
mistake of transplanting an entire ovary instead of one or more small 
pieces of it. The entire ovary is so large that there will be autolysis and 
complete destruction of most of the transplanted organ before blood-vessels 
have had time to grow in to maintain its life. 

As in the experimental work,- autografts have proved more useful than 
heterotransplants. But Martin notes that either type of transplant may 
undergo cystic degeneration. So long as a sufficient quantity of ovarian 
tissue remains, the transplant is able to sustain normal sex life, including 
menstruation. But, at the best, ovarian transplantation for clinical pur¬ 
poses is so far only a temporary expedient. The cause of the ultimate 
atrophy of the ovarian graft, once adequately vascularized, is not known. 

Chemistry of Ovarian Extracts. —The ovary produces, in all prob¬ 
ability, several hormones, but none of them has so far been isolated and 
chemically defined or detected in the blood, although Youatt claims that 
cows can be brought on rut by feeding them milk from cows in rut. 
Lillie has shown that the mature ova of certain invertebrates secrete 
a substance which acts on the sperm to render it capable of penetrating 
and fertilizing the ovum. In the absence of this substance union of 
ovum and sperm does not take place. This substance thus appears to act 
like the opsonins in phagocytosis. The substance is named “fertilizin’’ by 
Dr. Lillie. It can be extracted from the ripe ova by various means and 
thus shows some stability. It is likely that similar fertilizing have a 
role in the processes of union of sperm and ovum in the vertebrate, in¬ 
cluding man, but this hormone or secretion is obviously not concerned 
in the development and maintenance of sex life, as ripe ova are not present 
before adolescence, and after adolescence they are present only at definite 
periods. 

Hermann reports that he has isolated a pentaminphosphatid from the 



Fig. 19. —Effect of Spaying on Growth in the White Rat. Solid line represents 
control; broken line represents spayed rats of same litter. (Hatai.) 










THE OVARIES 745 

corpus luteum. He claims that injection of this substance into animals 
causes hyperemia of the uterus. 

Seitz, Wintz and Eingerhut report that they have isolated two physio¬ 
logically active substances from the corpus luteum: (1) a luteolipoid, 
and (2) lipoprotein, or lecithalbumin, called “lipamin.” They state that 
the injection of the latter into animals stimulates the growth of the 
genitalia, while its injection into women suffering from amenorrhea in¬ 
duces menstruation. The luteolipoid, on the other hand, is said to decrease 
the menses, and therefore be useful in menorrhagia, especially the exces¬ 
sive menstruation of puberty. We may remark that these two bodies 
were not chemically isolated and identified, and the clinical findings are 
not conclusive. For example, the amount of the menses is not accurately 
determined. According to the theory proposed by Seitz, Wintz and Fin- 
gerhut normal menstruation is a function of the proper balance of the 
“luteolipoid” and the “lipamin” secretions of the corpus luteum. This 
seems untenable for the following reasons: (1) These substances were 
prepared from the corpora lutea of animals that do not menstruate. 

(2) In women menstruation is usually suppressed by pregnancy despite 
the persistence and great development of the corpus luteum of pregnancy. 

(3) Menstruation (or rut) may precede ovulation and, hence, may pre¬ 
cede the appearance of corpora lutea. Doisy and Allen have recently re¬ 
ported the isolation of a hormone from the liquor folliculi that appears to 
control estrus in animals. 

Specific Role of the Corpus Luteum. —The sex life of the mature 
mammalian female is much more complex than that of the male. With 
it are associated ovulation, gestation and the nursing of the newly bom. 
A very complicated situation is the practical absence of menstruation in 
all mammals below the primates, the relative scantiness of menstruation 
in all primates below man, and the apparently serious symptoms asso¬ 
ciated with amenorrhea as well as menorrhagia in women. It is possible 
that amenorrhea per se may not be serious, but that the symptoms are 
due to the underlying causes that suppress the menses. Menorrhagia is, 
of course, serious by itself, in that it may produce anemia. There is no 
question but that menstruation in women is primarily a function depend¬ 
ing on the mature and normal ovary. Hoes the fact that menstruation 
occurs in women, but not in the lower mammals, indicate a fundamental 
difference in ovarian physiology in the primates? The answer to this 
question is of fundamental importance to practical ovarian organotherapy, 
as the only available material for such therapy is the ovaries of the lower 
mammals. So far as we know, ovarian materials from the apes have 
not been tried, clinically. 

The corpus luteum is a temporary organ, essentially of the mammalian 
ovary, but it is also present in birds. The obvious parallelism of this 
organ with menstruation and pregnancy has naturally directed expen- 


746 ORGAN OTHERAPEUTICS 

mental and clinical attention to this organ as a factor of control in these 
processes. The work of Frankel, Marshall, and Loeb appears to have 
established the following facts: 

1. The corpus luteum is necessary for uterine changes involved in 
the implantation and early stages of growth of the fertilized ovum. 
Ovariotomy or destruction of the corpus luteum by cautery in early preg¬ 
nancy (first few days or weeks, the time varying in different species) 
invariably terminates the pregnancy. When the corpus luteum is de¬ 
stroyed or the ovaries removed later, 
the course of the pregnancy or the 
hypertrophy of the mammary gland 
is not interfered with. The latter 
statement is also confirmed by clinical 
results. Ansel and Bouin, and 
especially Loeb, have shown that these 
changes in the uterus induced by ovu¬ 
lation and the corpus luteum do not 
appear to depend on the fertilization 
of the ovum. 

It must be remembered, however, 
that there is some hypertrophy of the 
ovarian stroma parallel with the 
development of the corpus luteum of 
pregnancy, and from the further fact 
that the luteal cells are derived from 
the stroma, there remains the possi¬ 
bility that the stroma cells share in 
the above role of the yellow body in 
early pregnancy. 

2. The corpus luteum of pregnancy appears to delay the maturation 
of the ova, thus preventing ovulation. This is probably not entirely a 
local action on the ovary, for a well-developed corpus luteum on one 
ovary appears to be able to inhibit ovulation in the ovary of the opposite 
side. Pearl and Surface report that administration of corpus luteum to 
hens causes a temporary inhibition of ovulation. 

3. The corpus luteum appears to play a part in the hyperplasia of 
the mammary gland that occurs during pregnancy (Ansel and Bouin, 
O’Donoghue, Hammond and Marshall, Ott and Scott). It is stated that 
if the graafian follicle of a virgin rabbit is ruptured by mechanical means, 
so that a corpus luteum is formed, hyperplasia of the mammary glands 
is produced, and also that administration of corpus luteum to virgin 
animals induces hyperplasia. But the situation is complicated by the 
findings of Miss Lane-Claypon and Starling, and of Aschner, that similar 



o. 4 

Fig. 20. —Record of Dog Showing Re¬ 
action to 0.5 Cubic Centimeters 
Nicotin (1:2,000 Dilution), a, be¬ 
fore, and b, 46 Days after Extir¬ 
pation of the Ovaries. Blood-pres¬ 
sure from femoral artery. Time, 5 
seconds. (Hoskins.) 



THE OVARIES 


747 


injections of fetal and placental extracts into virgins also cause hyper¬ 
plasia of the mammary gland. 

4. Experimental work does not support the view of Frankel that the 
corpus luteum induces or controls estrum, or menstruation, as in some 
animals, at least, the proestrous and estrous uterine hyperemia precedes 
ovulation and therefore takes place in the absence of corpora lutea in 
the ovary. 

Alleged Antagonism between Testicular and Ovarian Hormones.— 

While the sex life, especially of the mammalian female, is more complex 
than that of the male, the essential nature of the sex urge appears to be the 
same in both sexes. This would seem to indicate similar or identical sex 
hormones. The sex urge and the development and maintenance of the 
secondary sex characters depend on the ovaries and testes, and given 
the different embryological substrate for the characters it would seem that 
these might be stimulated to normal development by identical hormones. 
Recent experimental work does not support this view. The essential 
hormones of the ovaries and testes appear not only to be different, but 
mutually antagonistic, at least in certain stages of development, and yet 
they produce, directly or indirectly, the same or similar mental states in 
male and female. 

We have already referred to the work of Steinach, Riddle, Sand, 
Moore, and others, of producing “maleness” in the female and “female¬ 
ness” in the male by changing the gonads, or administration of gonad 
extracts of the opposite sex. But the most significant contribution to 
this subject has been reported by Lillie. Lillie’s work was done on the 
freemartin. The term “freemartin” is applied to the female of hetero¬ 
sexual twins of cattle. It is well established that such females are usually 
barren. Lillie finds that a twin pregnancy in cattle is almost always 
a result of the fertilization of an ovum from each ovary; development 
begins separately in each horn of the uterus. The rapidly elongating 
ova meet and fuse in the main body of the uterus at some time between 
the 10-millimeter and the 20-millimeter stage. The blood-vessels from 
each side then anastomose in the connecting part of the chorion; a par¬ 
ticularly wide arterial anastomosis develops, so that either fetus can be 
injected from the other. The arterial circulation of each also overlaps 
the venous territory of the other, so that a constant interchange of blood 
takes place. If both are males or both are females no harm results 
from this; but if one is male and the other female, the reproductive system 
of the female, especially the ovaries, is largely suppressed, and certain 
male organs develop in the female. This is, according to Lillie, uncpies 
tionably to be interpreted as a case of hormone action. The sterilization 
of the female by the male appears to be due to more precocious develop¬ 
ment of the fetal male hormones. There is no dominance of testes lior- 


748 


ORGANOTHERAPEUTICS 


mones over ovarian hormones after birth or in adults. At any rate 
Moore reports that successful testes graft in female rats does not influence 
the ovaries in the sex life (rut, pregnancy, lactation, etc.). 

If these observations and interpretations of Lillie are confirmed and 
extended to other animals, we have the extraordinary fact of the develop¬ 
ment of specific gonad hormones before the gonads have undergone any 
appreciable differentiation. If this shall prove to be the case, these hor¬ 
mones can be produced by nothing else than the primitive germ cells. 

We have evidence that other endocrine glands (pancreas, thyroid) 
assume functional importance sometimes during intra-uterine life, but 
the observations of Lillie place the beginning of fetal hormone equilibrium 
earlier than hitherto thought possible. It also raises the question of the 
exchange of gonad hormones between the fetal and the maternal blood. 
The bearing of a male child obviously does not influence the sex life 
of the mother. Lillie’s interpretation of the genesis of the freemartin 
is called in question by the condition of true hermaphrodism—ovaries 
and testes being present in the same individual, or testes being present 
with the secondary sex character of the female and vice versa. In the 
lower animals who normally harbor both ovary and testes (ovo-testis) 
in the same individual, or whose gonads may produce sperm during one 
period and ova at another period, definite secondary sex characters are 
usually absent. 

Experimental Administration of Ovarian Extract.—We have seen 
that complete extirpation of the ovaries leads to atrophy of the uterus, 
mammary glands, and other sex characters. These are anatomical or 
objective changes that may be accurately measured. It would, therefore, 
seem that it ought not to be difficult to decide whether ovarian adminis¬ 
tration is capable of preventing or diminishing these effects of ovariotomy. 
Nevertheless, the literature is conflicting. Jentzner and Beutner and also 
Carmichael and Marshall state that ovarian administration fails to pre¬ 
vent the atrophy of the uterus. Okiiichitz claims, on the other hand, 
that the uterine atrophy following spaying is prevented by injections 
of extracts of the entire ovary, by extracts of the follicular tissue, and by 
extracts of the chorion, but not by extracts of the corpus luteum. The 
corpus luteum of pregnancy inhibits ovulation, but administration of 
luteal extracts does not inhibit ovulation (Corner). 

Various toxic effects have been observed from injections of ovarian 
extracts (for example, disturbance of calcium and phosphorus metabolism) 
particularly in pregnant animals. Ssoloviev reports that corpus luteum 
and ovarian extracts administered subcutaneously to lactating animals 
cause increased secretion of milk, and at the same time general deleterious 
effects leading to death of the animals. These injections are said to be 
non-toxic in non-pregnant and non-lactating animals. This action of 
ovarian extract on the mammary gland was also noted by Ott and Scott. 


THE OVARIES 


749 



continuous line represents reactions 
before; the broken line after castra¬ 
tion of dog. (Wheelon.) 


Mackenzie reported that it is absent from extracts of ovaries containing no 
corpus luteum. The substance must, therefore, be a product of the latter 
organ. This mammary gland action of corpus luteum is, like that of 
pituitrin, not a true secretion of milk, 
but the stimulation of the smooth muscle 
in the walls of the mammary alveoli, thus 
expelling the milk that has already been 
formed (Schafer). 

Itagaki, a pupil of Schafer, reports 
that extracts of the hilum (interstitial 
cells) of the ovary depress the tone and 
contractions of the uterus. Extracts of 
the follicular tissue, and the liquor 
folliculi itself, produce increased tone 
and stronger contractions of the uterus. 

Whether these substances are artefacts, 
or normal products assuming a role in Fig - 21. —Composite Curves Showing 
life, for example, in the uterine cramps Flood - pressure Responses to 

£ • r i , ,. • • . Standard Doses of Nicotin. The 

of painful menstruation, is an important 

practical question that calls for speedy 

solution. According to Sack, corpus 

luteal tissue added to the food of rats 

tends to produce adiposity. Fichera states that the enlargement of the 

hypophysis following spaying is prevented by ovarian feeding. 

Therapeutic Use of Ovarian Preparations.—At present the use of 
ovarian preparations as organotherapeutic agents is confined to gyne¬ 
cology, and their detailed discussion properly belongs in special works 
on this subject. But it is possible, however, that with increasing knowl¬ 
edge of the relations of these glands to other organs of internal secretion 
they acquire importance in connection with general internal medicine. 

The definite conditions where the ovarian organotherapy might prove 
useful are infantilism in girls, and the menopause, artificial and physio¬ 
logical, as these conditions are clearly due to ovarian hypofunction. 

Many writers report favorable results in menopause cases. The 
attacks of giddiness, trembling, palpitation, flushings, sweatings, and other 
nervous and vasomotor disturbances are reported to be much reduced 
in number and severity, or to have ceased entirely in some cases. The 
best results are obtained in cases of postoperative menopause, especially 
in young women. Relapses are said to occur after stopping the treat¬ 
ment. Many cases have been reported in which the results were nega¬ 
tive, and in some of those with improvement suggestion may have been 
an important element. The most judicial and convincing clinical contri¬ 
bution to ovarian therapy in recent years is that of Novak. On the 
basis of his own extensive clinical experience as well as his critical analysis 



750 


ORGANOTHERAPEUTICS 


of the literature, Novak concludes that, to date, clinical ovarian organo¬ 
therapy is purely experimental; that taking the natural history of hypo- 
ovarian disorders into consideration, one cannot say as a proved fact 
that ovarian administration has had any beneficial effect, apart from 
the element of suggestion. 

Excepting the menopause, practically all the disorders of sex life 
of women may be due to causes other than a primary ovarian deficiency, 
so that the use of ovarian preparations in all of these conditions is at 
present largely empirical, both because of the uncertainties of diagnosis 
and because of the uncertainty as to the kind of ovarian therapy indicated. 
As Marshall has aptly remarked, “it would seem unreasonable to expect 
to obtain uniform results from the indiscriminate uses of ovaries in differ¬ 
ent stages of cyclical activity, for example, ovaries with prominent follicles 
like those from animals in heat, or ovaries with corpora lutea like those 
of pregnant animals, or ovaries in a state of relative quiescence like 
those of anestrous animals.” And it must not be forgotten that ovaries 
of many of the lower animals also differ markedly from those of man, 
in accordance with the differences in the sex life. For that reason ovarian 
material from the apes should be given a thorough trial. Some of the 
conditions in which ovarian medication has been tried, with varying 
degrees of success, are infantilism, amenorrhea, dysmenorrhea, sterility, 
repeated abortion, hyperemesis gravidarum, toxemia of pregnancy, pruri¬ 
tus vulvse, deficient milk secretion. Watson reports that he has rarely 
seen any good effects from ovarian extracts in any of these conditions. 

In recent years, following the work and theories of Frankel, the 
corpus luteum, or extracts of this organ, has largely replaced the extract 
of the entire ovary in the therapy of female sex disorders. This is unfortu¬ 
nate, as Frankel’s theory is, at least in part, untenable. From extensive 
studies on the guinea pig, Leo Loeb concludes that the presence of a 
functionating corpus luteum is necessary for certain of the cyclic changes 
in the uterus; for other uterine changes the absence of the yellow body 
is necessary, while for still other phases of the cyclic uterine changes 
other ovarian structures (probably mature follicles rather than the so- 
called interstitial cells) are required. But, practically, it may make 
little difference, as it is not likely that any drug manufacturer is so 
careful that all ovarian stroma and follicular tissue are excluded from 
his luteal preparations. 

Clinical experience, however, has not been uniform. Frankel reports 
more or less favorable results in disturbances of the menopause, etc.; 
but the drug had no effect on dysmenorrhea, irregular menstruation, and 
the intoxications of pregnancy. 

Recently it has been especially recommended in cases of amenorrhea 
and scanty menstruation, and when there are nervous symptoms which 
may be due to this insufficiency. It is said by some to increase the men- 


THE OVARIES 


751 


strual flow, and to prevent nervous conditions accompanying their func¬ 
tional deficiency. 

Krusen states that in so-called ovarian insufficiency improvement usu¬ 
ally follows corpus luteum administration if persisted in for a long 
time. Burnam reports good results from corpus luteum, given by mouth, 
in menopause, functional amenorrhea in young women, sterility and re¬ 
peated abortion. Burnam states that corpus luteum does not induce men¬ 
struation in the complete absence of the ovaries. This is contradicted 
by Donnereuther (one case, no control). This author, using the corpus 
luteum of pregnant cows, reports uniformly good results in menopause, 
functional amenorrhea and dysmenorrhea, sterility not due to infection 
or mechanical defects, hyperemesis in early pregnancy, repeated abortion, 
neurasthenic symptoms during menstruation, etc. Culbertson reports 
good results from corpus luteum feeding on the vasomotor disturbances 
of the menopause. Other clinicians report negative or indifferent results 
from corpus luteum therapy in all of these conditions. Dalche states 
that in dysmenorrhea long-continued use of thyroid gives better results 
than preparations of the ovary. In Frankel’s hands corpus luteum gave 
results only in menopause cases. Leighton states that a small number 
of cases of dysmenorrhea, presumably due to ovarian hypofunction, are 
improved by giving corpus luteum, 15 to 20 grains per day, for a long 
time. In some instances this medication caused gastro-intestinal dis¬ 
orders, but no other untoward effect. According to Climenko, corpus 
luteum extracts do not act as hormones, and cannot take the place of a 
functional corpus luteum. He thinks these extracts may stimulate an 
intact but hypofunctioning corpus luteum. 

In view of the fact that so many physicians have reported good results 
from corpus luteum therapy in the amenorrhea of adolescence , we were 
struck by the recent paper of Landsberg in which he claims to have cured 
seven cases of menorrhagia of adolescence by a corpus luteum prepara¬ 
tion. It would thus appear that the very opposite conditions, amenorrhea 
and menorrhagia, are both controlled by the same agent, corpus luteum! 
It is probable that, the luteal therapy has no causal relation to the im¬ 
provement or cure of either condition, as there is no evidence that the 
yellow body influences menstruation except directly through its inhibitory 
control of ovulation. At any rate we must conclude that, so far, medical 
science has failed to reproduce (experimentally or clinically) by luteal 
extracts the effects produced by the intact corpus luteum. The intact 
corpus luteum inhibits ovulation, luteal extracts do not. 

Causes for Failure of Ovarian Therapy—These are probably complex. 
We mav destroy or lose the ovarian hormones in the preparation of the 
substance, as in the degreasing process of preparing the ovarian extracts 
or powder. The hormones may be destroyed in the alimentary canal, 
or fail to be absorbed. There are indications, for example, that the gonad 


752 


ORGANOTHERAPEUTICS 


hormones do not pass through the placenta. Finally, it must ever be 
kept in mind that practically all the disorders of the sex life of women 
may have their initial cause outside of ovarian hypofunction. It is 
well established that amenorrhea may come as a result of quantitative 
and qualitative undernutrition, anemia, chronic infection, hypothyroidism, 
and possibly from hypopituitarism. This may seem to he an argument 
for polyglandular organotherapy in disorders of sex function in women. 
But, because of the failure of ovarian therapy in frank or certain ovarian 
hypofunction, there seems to me no good reason for adding ovarian extract 
to thyroid extract in our endeavor to reestablish menstruation suppressed 
by myxedema. 

Methods of Preparation and Administration.—The ovary (usually of 
the cow) has been administered by mouth in the fresh and dried state, 
and in the form of various extracts, both orally and subcutaneously. At 
present it is most frequently fed in the form of the dried fat-free powder, 
in doses of 0.06 to 0.5 gram (1 to 8 grains) or more, three or more 
times a day. As it sometimes causes disturbances of digestion, its use 
may be interrupted at times. 

The dried gland is frequently administered in the form of tablets; 
the designation of the weights of the commercial tablets is as lacking 
in uniformity as in the case of thyroid tablets. 

The dried, powdered corpus luteum (also called “lutein”) has been 
administered in doses of % to 2 grains (0.03 to 0.12) or more, three 
times a day. It has been used in the form of various extracts. Maits 
used a sterile 1 per cent extract of the corpus luteum in normal saline 
solution injected subcutaneously in doses of 10 c.c. 

No clinical progress can be expected from further use of commercial 
preparations until methods of chemical and physiological standardization 
of ovarian products have been worked out and applied. 

Summary 

1. The ovaries produce several physiologically important substances 
or hormones, none of which have been isolated and chemically defined. 
There is no reliable evidence that any or all of these hormones are present 
in any ovarian extract so far made for experimental or therapeutic pur¬ 
poses. The development and maintenance of the secondary sex characters 
of the female is clearly a function of the ovarian stroma and possibly 
the immature follicles. The initiation of estruation or rutting is evi¬ 
dently a function of the mature follicles primarily. The corpus luteum 
is essential for the processes of the early stages of pregnancy. It also 
retards the maturation of other graafian follicles, thus preventing estrum, 
menstruation, and ovulation during pregnancy. The ovarian hormones 
thus control, in part, the activity of the ovaries themselves, and the 


753 


THE FETUS AND THE PLACENTA 

specific sex functions of distant organs, such as the uterus, the placenta 
and the mammary glands. 

2. The menopause syndrome, natural and artificial, is primarily due 
to absence of or hypofunction of the ovaries. All other disorders of the 
sex life of women may be due to complications outside the ovaries. Some 
of these complications involve other endocrine glands, notably the thyroids, 
possibly the hypophysis and the adrenals. In these conditions diagnosis 
is frequently uncertain, and, unless the malady is clearly due to ovarian 
hypofunction, ovarian organotherapy cannot be expected to yield results. 

3. In the present state of ovarian physiology, organotherapy of the 
natural and artificial menopause should be undertaken with the extract 
of the entire ovary rather than with corpus luteum preparations, as the 
role of the latter organ concerns some phases of the early stages of preg¬ 
nancy and suppression of ovulation, while the other ovarian tissues sustain 
the fundamental processes of sex life. 


THE FETUS AND THE PLACENTA 

Chemical substances or hormones yielded by the growing fetus (and 
possibly by the placenta) to the maternal blood appear to control the 
hyperplasia of the mammary gland during pregnancy, even to the point 
of actual initiation of the milk secretion (Lane-Claypon and Starling, 
Aschner). This is probably the normal mechanism, although there are 
cases on record of mammary hyperplasia and milk secretion in adult 
virgins and even in males. But there is no practical therapeutic applica¬ 
tion of this fact, as there is no reliable evidence that feeding placenta 
or fetal extracts will improve the quality or quantity of milk in nursing 
mothers (Hammet and McNeile) or develop the breasts in cases where 
this may be desired for cosmetic reasons. Aschner reports that placental 
extract causes ovarian hyperemia, uterine congestion and hyperplasia, 
hence he suggests the use of placental extracts in amenorrhea and sterility. 
Van Hoosen, Cornell, and Hammet have reported that daily feedings of 
dried placenta to mothers during the first few weeks of lactation lead 
to increased growth of the nursing infant. They conclude from this that 
the placenta produces a growth-stimulating hormone, and suggest that this 
hormone may be a factor in the growth of the fetus. The results reported 
by Hammet, even if corroborated, may be due to dietary factors also found 
in other tissues. 

Summary 

There is at present no reliable evidence that the placenta secretes a 
hormone or hormones, having useful or important actions on the mother 
or the fetus, actions that can be duplicated by feeding placenta. Hence, 
there is as yet no placental organotherapy. 


754 


ORGANOTHERAPEUTICS 


THE MAMMARY GLAND 

The mammary gland is an organ found only in the highest group of 
vertebrates, rudimentary in the male, and in the female active only for a 
certain period after parturition. It is not likely that an organ so limited 
in its distribution and activity has itself any important influence on the 
vital processes of the mammalian female. The important problems in 
mammary gland physiology are the dietary and hormone mechanism of the 
gestation hyperplasia and the postpartum milk secretion. 

There is not much evidence that the mammary gland produces an in¬ 
ternal secretion, beyond the fact that, in women, menstruation is usually 
in abeyance during the height of lactation, but in other mammals heat 
or estimation appears shortly after parturition. There is, however, some 
evidence that it contains substances which have effects (probably not 
specific) upon metabolism. Thus Hunt reports that, when mammary 
gland is fed to animals, it causes changes in metabolism analogous in 
certain respects to those caused by thyroid feeding. 

Complete removal of the mammary gland in the adult female is not 
known to produce any but psychic and cosmetic effects. The complete 
removal of the mammary glands in young females is said to retard sexual 
maturity and the growth of the uterus (Scherbak). But such mutilated 
females become pregnant and give birth to young, as under normal condi¬ 
tions. Nursing hastens the involution of the uterus (rat, guinea pig). 
This effect is produced even after spaying (Kuramitsu and Loeb). This 
may be merely an effect of the increased metabolism in connection with the 
active lactation. 

Injections of mammary gland extracts are said to retard the develop¬ 
ment of the ovaries and the external genitalia (Schiffmann and Vystavel). 
According to Adler they inhibit heat and conception, and in gravid 
animals cause abortion. 

According to Osborne, Luncz, and others, mammary gland extracts 
decrease uterine hemorrhages. Several authors (Bell, Fedoroff, Mekert- 
schiants) report the cure of uterine fibromas and myomas by these injec¬ 
tions! Sellheim proposes the removal of the mammary gland to cure 
eclampsia ! Hammet guesses that stimulation of the breasts releases 
mammary hormones into the blood, hormones that cause contraction of the 
uterus ! Healy and Kastle suggest that a mammary hormone is responsible 
for the initiation of labor! 

Mackenzie claims that the mammary gland contains a true galacta- 
gogue or milk-producing hormone. This would be of great clinical im¬ 
portance, if true, but Gavin contradicts it squarely, and, in the light 
of Gaines’ work, .the results of Mackenzie are in all probability erroneous. 

There is no reliable evidence that the mammary gland is an endocrine 


THE TESTES 


755 


organ, 01 that feeding mammary gland substance produces any specific 
01 useful effects in health or disease. Hence, there is no rational or useful 
organotherapy of the mammary gland at present . 


THE TESTES 

Physiology. The testicles, at least of the higher vertebrates, contain 
two distinct types of cellular elements having evidently different func¬ 
tions: (1) the interstitial cells of Leydig; and (2) the spermatogonia, 
which develop into spermatozoa. The role of the spermatogonia and 
spermatozoa is clear, namely, the fertilization of the female ovum. This 
fertilization involves two factors on the part of the male element : (1) a 
stimulus to development of the ovum; and (2) a vehicle of paternal 
heredity. In performing these functions the spermatozoa act, from the 
point of view of the male, as an external secretion. 

Numerous attempts have been made to isolate the substances in the 
spermatozoa concerned in these two functions. In the case of some of the 
lower animals various extracts of the sperm are reported to induce develop¬ 
ment in the ovum, hut there is no evidence that the paternal hereditary 
factors can be conveyed to the ovum by bathing the ovum in sperm 
extract. 

The interstitial cells of Leydig vary greatly as regards relative abun¬ 
dance in the testes of different species. They are quite abundant in man. 
In embryonic development the interstitial cells antedate the spermatogonia. 
In animals showing seasonal periodicity in sex activity, the interstitial 
cells appear to be more abundant during sexual rest than during the 
period of rut (Tandler and Gross). The interstitial cells exhibit greater 
resistance to various agencies. Exposure of the testicle to the X-rays 
leads to degeneration and atrophy of the spermatogonia before that of the 
interstitial cells. In testicle transplants, in the condition of cryptorchid¬ 
ism, and after ligation of the vas deferens, the cells of Leydig persist, 
apparently in normal condition, long after atrophy of the spermatogonia. 
But recent work of Moore on rats and guinea pigs seems to show that 
ligation of the vas does not always induce atrophy of the seminiferous 
tubules. 

Influence of Congenital Absence, Atrophy, or Extirpation of Testi¬ 
cles.—The effects of castration have been known for a long time through 
its extensive practice in animal husbandry, and on boys and men for re¬ 
ligious and social purposes in various countries. Removal of the testicles 
in the young vertebrate male has the following effects: 

1. It prevents the development of all the secondary male characters 
(penis, prostate gland, beard, male larynx, male skeletal characters, skin 


756 


ORGANOTHERAPEUTICS 


and feather colors, horns, etc.). In some of the invertebrates' the castra¬ 
tion has no effect on the body male characters. In species where horns 
are not a sex character, castration has no effect on the horn growth. 

2. It delays the ossification of the long bones, and the union of the 
sutures of the skull. 

3. It leads to certain changes in the endocrine glands, the most 
notable being the enlargement of the hypophysis, and the adrenal cortex, 
and the retarded involution of the thymus. The growth of the thyroid 
is said to be diminished. But Moore has recently reported that castra¬ 
tion in the young guinea pig decreases the growth of the hypophysis, the 
adrenals, and the spleen, and causes increase in the size of the thyroid. 
Evidently this aspect of gonad function requires further investigation. 

4. The rate of metabolism is somewhat lowered, with a tendency to 
adiposity; vasomotor irritability (sympathetic system) is said to be 
decreased. 

5. The most notable mental change in the castrated male is absence of 
the boldness, pugnacity, and viciousness of the normal male, particularly 
during the breeding season. In this respect the castrated male may be 
said to resemble the child or the female. This comparison must not be 
carried too far. Hikmet and Regnault say of the eunuchs of Constanti¬ 
nople, that “they are avaricious, stupid, credulous, illogical, obstinate, 
fanatical, fond of children and animals, faithful in their affections but 
lacking in courage.” But the reader will admit that this characteriza¬ 
tion will fit many a man with intact and normal testicles. 

6. There is little or no development of the sex urge in its various 
manifestations. 

When the testes are removed in the adult male the most notable 
changes induced are: 

1. Sexual impotence and diminution or loss of sex urge. 

2. Tendency to atrophy of the secondary male characters. 

3. Lowered rate of metabolism and tendency to obesity. 

The striking specificity of the influence of the testes on organs is 
shown in the case of the growth of horns. Horns are modified skin struc¬ 
tures apparently identical in all mammals having these organs. Never¬ 
theless in species where the horns constitute a specific male character, 
castration prevents their development, while in the species where the 
horns are common to both sexes, castration has no effect on their growth. 

Thus we see that atrophy or extirpation of the testes leads to impair¬ 
ment and final loss of all structures and functions specific for the sex life 
of the male, but it does not bring on any serious disturbance of other 
functions. There are no sequelae comparable to those of the artificial 


THE TESTES 


757 


menopause in women. There is no reliable evidence that castration 
shortens the span of life or measurably impairs the individual’s physical 
and mental efficiency. Senescence in the male is, therefore, not a direct 
consequence of hypofunction of the testicles but the result of age im¬ 
pairment of all the tissues. 

On the basis of extensive studies on the effects of gonadectomy in the 
rat, Hatai concludes that “the partial removal of the sex glands does not 
produce any significant alterations in any of the ductless glands aside 
from a general tendency to a slight increase. Apparently this increase in 
the remaining gland is sufficient to compensate for the functions of the 
lost gland.” 

“The total removal of sex glands, however, induces alterations in all 
the other glands, particularly in the thymus and hypophysis. The supra¬ 
renal glands show opposite reactions in the two sexes. In the case of the 
males, the suprarenal glands show an increase of 15 per cent, while in the 
female there is a 20 per cent reduction. 

“The total removal of the sex glands tends to increase the resemblance 
between the two sexes or, in other words, to reduce the differences in those 
secondary characters which, in the normal animal, are modified according 
to sex.” 

Function of Interstitial Cells.—The following facts seem to show that 
the development and maintenance of the sex life in the vertebrate male is 
primarily a function of the interstitial cells. 

1. In cryptorchidism there may be complete atrophy and absence 
of spermatozoa and spermatogonia, but, if the interstitial cells are pres¬ 
ent, sex structures and sex functions remain normal. These males are, 
of course, sterile. 

2. After ligation of the vas deferens, the spermatogonia suffer gradual 
and, finally, complete atrophy, but as long as the cells of Leydig are 
intact sex life remains unimpaired. Extirpation of such modified testes 
brings on the usual sequelse of castration. Steinach claims that ligation 
of the vas induces hypertrophy of the Leydig cells. 

3. Testicular transplants maintain sex life as long as sufficient quan¬ 
tity of the interstitial cells continues to live, irrespective of the degenera¬ 
tion of the sperm-producing elements, and extirpation of such partially 
degenerated grafts brings on the typical symptoms of castration. 

The control of the sex life of the male by the cells of Leydig is evi¬ 
dently a humoral one, as a denervated testis and a testicular transplant 
in another organ, and thus, outside of its normal sensory nerve relations, 
functions for a time like a normal testis, except for fertility. This is 
also indicated by the fact that men with complete transverse lesions ol 
the spinal cord, provided the trauma is not great enough to cause marked 


758 


ORGAN OTHERAPEUTICS 


mental and physical depression, from the beginning retain their inclina¬ 
tion toward the female sex, although they can no longer experience the 
sensations due to erection and coitus. 

Relation of Interstitial Cells of Testes to Cortical Cells of Adrenals; 
Hypergenitalism.—From the field of histology and organogenesis, evi¬ 
dence has been adduced to show that the cells of Leydig in the testes and 
the cells of the interrenal or the cortical system arise from the same 
embryological anlage. This may be accepted as true, but it does not con¬ 
stitute a proof that in their adult differentiation the functions of these 
cells are identical or reciprocal. Instances are also related in the litera¬ 
ture of tumors (hyperactivity) of the adrenal cortex producing sexual 
precocity in boys. This is significant, if true, and if there is no evi¬ 
dence of premature development of the testes themselves. Tumors of 
the testicles may also induce sexual precocity. However, it is clearly 
established that no other gland in the body can assume the role of the 
interstitial cells in sex life. After castration in a normal animal the 
other endocrine glands either remain normal or undergo some hypertrophy. 
These hypertrophies, even in the case of the adrenal cortex, cannot be of 
compensatory nature, at least as regards the specific sex role of the testes, 
since they do not maintain sex life. If the hypertrophies are compensa¬ 
tory it must he in relation to some general metabolic or detoxication func¬ 
tion that the testes have in common with other endocrine glands. 

Chemistry of Testes.—The nature of the processes or the substance in 
the interstitial cells that sustains the male sex life remains unknown. 
Poehl claims to have isolated a substance from the entire testicle, having 
the formula C 5 H 14 N 2 and called by him “spermin.” He reports that this 
substance is the physiologically active constituent of testicular extracts, 
and, injected hypodermatically, it accelerates metabolism and acts as a 
general physiological tonic. Dixon found an abundance of nucleoproteins, 
other products, organic bodies not affected by boiling, and inorganic salts 
in extracts of the testicles. Hernieux reports the presence of lipase and 
amylase in the interstitial cells. With the possible exception of Poehl’s 
spermin, there appears to be nothing specific in these findings. Similar 
substances are found in all organ extracts. 

From a series of very interesting experiments on male frogs, Nuss- 
baum concludes that the testicular secretion acts primarily upon the 
nervous tissue as a tonic or a stimulus, and the augmented or altered 
activity of the nervous tissue, in turn, sustains the sex life. This view 
is probably true in specific cases, but cannot be accepted as a complete 
statement of the situation. 

Clinical and Experimental Uses of Testes Extracts— Experimental. 
—Bouin and Ancel report that injection of testicular extracts into cas¬ 
trated guinea pigs prevents the atrophy of the male characters. Accord¬ 
ing to the same authors this extract also accelerates the growth of the 


THE TESTES 


759 


animals. Loewi states that giving testicular extracts to young capons 
induces development of the male characters. Walker was unable to pre¬ 
vent the atrophy of the prostate in castrated dogs by injection of testes 
extracts. Walker and Kiddle have reported that administration of testic¬ 
ular extracts to female animals (chickens, pigeons) tends to produce male 
characters and male behavior. It has been demonstrated by Meisen- 
heimer that in castrated male frogs the characteristic development 
of the forelegs at the breeding season can be induced by testes 
extracts. 

Clinical. The testes, variously prepared, was used by the ancient 
Greeks and the Hindus as an aphrodisiac and tonic. Its modern use in 
that direction dates back to Brown-Sequard, in 1889, who administered 
extracts of the testes to himself and thought he experienced a great 
augmentation of bodily and mental vigor. Zoth, and Pregl, using the 
ergograph, report some evidence of increase in muscular work after sub¬ 
cutaneous injections of the extract. Similar results would probably have 
followed the injection of any tissue extract. In many of the reports of the 
action of the extract on normal persons the element of suggestion was not 
controlled. 

The work of Poehl and his associates with spermin was even more sen¬ 
sational than that of Brown-Sequard. Poehl regarded spermin as a gen¬ 
eral metabolic stimulant or catalyzer and reports good results from its 
use in the following maladies: Asiatic cholera, syphilis, erysipelas, de¬ 
lirium tremens, gas (CO) poisoning, chloroform and ether poisoning, 
impairment of heart and lungs, optic atrophy, hemiplegia, paralysis, 
catatonia, cholera, hysteria, neurasthenia, myelitis, scurvy, marasmus, 
skin diseases, typhoid fever, toxic goiter, pulmonary tuberculosis, diabetes 
mellitus, anemia and gout. This is a good example of organotherapy 
running amuck! There is no evidence that any of these maladies are 
in any way related to hypofunction of the testes. So far as we know 
there is no evidence that castration lowers the resistance to infection or 
otherwise produces conditions favorable to the above diseases. And par¬ 
ticularly in cases of toxic goiter, where the destructive metabolism is in¬ 
creased to a degree not found in any other disease, except high fevers, 
any therapy which still further augments the metabolism is clearly contra¬ 
indicated. But others have recommended the use of testicle extracts in 
toxic goiter, diabetes, obesity, eczema, etc. (Jones, Eriedlander, Bauffe, 
Burghart). 

Transplantation of the Testes.—Transplantation of the testes appears 
to be only a temporary measure, even under the most favorable conditions, 
as the graft is sooner or later completely absorbed, but as long as a sufficient 
amount of the tissue remains alive the graft is able to sustain sex life, 
even when, as in Nussbaum’s experiment, it is placed in the lymph sac. 
Wheelon and Shipley found that a testes transplant was not able to re- 


760 


ORGANOTHERAPEUTICS 


store the vasomotor irritability of castrated animals to its normal level, 
though there was some improvement. 

Morris has reported an instance of a testicle transplant apparently 
stimulating a dormant testicular remnant so that it hypertrophied into 
an apparently normal testicle. The patient had lost most of the testicles 
at the age of thirteen in a complication of mumps. The man, age twenty- 
seven, at the time of the testicular transplantation, showed some effects 
of castration. 

We have now a great body of data, experimental and clinical, on 
testicle transplantation (Steinach, Sand, Moore, Lespinasse). The sci¬ 
entific interest and biological significance of the problem is great. The 
clinical interest is concerned with the possibility of restoration of sexual 
potency, with attendant physical and mental stimulation (“rejuvenation”) 
in old men, the possibility of rejuvenation of partially atrophic testicles 
in younger men, and thus the restoration of male fertility, and the pos¬ 
sibility of counteracting the alleged physical and mental lethargy and 
anatomic stigmata that follow the loss of the testes in boys. The clinical 
work in testes transplantation has been further stimulated by the universal 
failure to counteract testes deficiency (interstitial cells) by feeding testes 
preparations in any form. The following facts seem established: 

1. If adequate surgical technic is used a fairly high percentage of 
“takes” is secured both from autotestes and heterotestes transplants, 
whether the graft is placed in the scrotum, under the skin, or in the 
peritoneal cavity. 

2. Practically in every case only the cells of Leydig survive, and 
the length of survival is variable. In rats and guinea pigs testes grafts 
may live at least six months. The most favorable clinical reports indicate 
a survival of from a few months to two years, but these cases have not 
been checked up by histological study of the graft. We have only the 
patient’s own word for his sex potency, and this is not always reliable. 
At present there is no evidence that the testes graft can live through the 
normal period of male adolescence. Why a testes graft, once adequately 
vascularized, undergoes atrophy within such a short time is not known. 

3. There is no reliable evidence that testes transplanted from goats 
or monkeys to man ever become vascularized and survive. The reliable 
evidence is all to the contrary. At present this type of surgery, when done 
for pay with definite promises of results, is quackery, and does the honest 
medical profession much harm. In this business the surgeon is the 
monkey, and the patient is the goat. 

4. The question of how long a human testicle will survive after it is 
removed from the body and used for grafting is not settled. Most mam¬ 
malian organs, particularly glands, die within a few hours after excision, 
probably from asphyxia, even when asepsis and low temperatures are main- 


THE PROSTATE GLAND 


761 

tained. Yet surgeons have reported successful testes grafts using testicles 
five days after extirpation from the donor. 

5. At present, the most that a testes graft can do, even temporarily, 
is restoration of libido and copulation power with synchronous increase 
in metabolism. Other alleged effects on mind and body are probably 
due to suggestion. Fertility is not restored. Testes grafts are, there¬ 
fore, at present, a biological futility, a catering by the surgeon to the 
elements of sex degeneracy in our species. 

Summary 

1. The specific sex characters and sex life of the vertebrate male are 
developed and sustained by hormones secreted by the testes. In the 
case of the mammals there are indications that some of these hormones 
begin to function in early embryonic life. The hormones that deter¬ 
mine development to full sexual maturity are probably different from 
those that sustain sex life during full sexual maturity. 

2.. Complete removal of the testes either in youth or after maturity 
prevents or abolishes sex life, but has no other significant or deleterious 
effect, physical or mental, on the individual. 

3. The only fields for rational organotherapy of the male gonads are 
the comparatively rare cases of atrophy, disease, or accidental loss of the 
testes. The rather meager experimental and clinical data on this point 
indicate that the administration of testicular extract, by mouth or par- 
enterally, does not sustain sex life. It cannot, of course, overcome 
sterility. On the whole, organotherapy of the testes , from present indica- 
tions , is very limited , and of little importance . 


THE PROSTATE GLAND 

The prostate gland is a secondary male character undergoing atrophy 
on castration and varying in size and secretory activity with the activity 
or dormancy of the testes. The prostate secretion mixes with the sperma¬ 
tozoa and forms a part of the seminal fluid. This prostatic secretion may 
be of importance in maintaining the nutrition and activity of the sperm. 

In these days of active interest in hormones, suggestions of internal 
secretion functions have also been made for the prostate. Macht. reports 
that feeding prostate to tadpoles stimulates growth, and hastens meta¬ 
morphosis. But this may be a dietary factor rather than an index of 
hormones. Feeding prostate gland to mammals has.so far yielded no clear 
effects. Macht was unable to demonstrate any impairment in mental 
ability and nervous coordination in prostatectomized rats, Reichel has 
described cells in the prostate gland similar to the Leydig cells in the 


762 


ORGANOTHERAPEUTICS 


testes. Kandaleon has reported hypertrophy of the mammary glands in 
two seventy-year-old men, following prostatectomy. This is at least not 
a frequent result of prostatectomy, as this is a common operation in mod¬ 
ern surgery, and we are aware of no reports similar to that of Kandaleon. 

During the active sex life of the male, the prostate gland depends on 
the testes; nevertheless, there is frquently a hypertrophy of the prostate 
in old men when the testes functions are definitely on the decline. This 
is an actual contradiction, since the prostatic enlargement in old men is 
glandular. 

Summary 

1. There is, at present, no reliable evidence that the prostate furnishes 
an internal secretion, since prostatectomy induces no demonstrable defects, 
prostate feeding is without influence, at least in mammals, and nothing 
even remotely resembling a hormone has so far been found in this gland. 

2. The use of prostate material in organotherapy is therefore with¬ 
out any basis, at present. The pseudomedical literature furnishes, of 
course, testimonials of cures of a variety of ailments from the growing 
pains of childhood to postoperative melancholia, and the drug-houses fur¬ 
nish prostate extract. Under these conditions, it is up to the doctor to 
furnish the antidote of common sense. 


THE PINEAL BODY 

The pineal body is an evagination of the embryonic neural tube. 
It is composed of ependymal cells in a framework of neuroglia and con¬ 
nective tissue. According to comparative anatomy, the pineal body 
represents the vestigeal remnant of a median eye, perhaps functional in 
some species of reptiles, but its histological structure, at least in youth, 
the effects of pineal tumors in man, as well as some of the experimental 
physiology of the organ in birds and mammals, indicate that it may be 
a gland of some importance, at least during pre-adolescence. Its physi¬ 
ological importance is, however, not yet clearly established. 

In man the pineal body continues to grow until the age of seven to 
eight years, when atrophy or involution sets in, so that in the adult the 
pineal body is made up mostly of connective-tissue cells and the so-called 
“brain sand.” The average weight of the gland in man is 0.22 gram. 
It takes 25,000 pineal glands of calves to make up one pound of dried 
gland substance (McCord). The size and structure of the pineal body 
appears to he identical in males and females. 

Jordan has noted the great abundance of the blood supply to the organ. 
The presence of sympathetic nerve fibers in the pineal body has also been 
asserted (Cajal). 


THE PINEAL BODY 


763 


Injections of Pineal Extracts.—The intravenous injections of ex¬ 
tracts of the pineal gland have revealed no action of specific physiological 
importance, at least for the circulation (Jordan and Eyster, Horrax, 
McCord). In large doses, pineal extracts lower the blood-pressure, but 
this is not specific. 

McCord states that subcutaneous injections of sterile pineal gland 
(young calves) into young guinea pigs three times weekly has a marked 
stimulating action on growth. 

Extirpation of the Pineal Body.—According to Biedl, Exner and 
Boese, and Dandy, extirpation of the organ in adult dogs or in rabbits 
(young or adult) produces no demonstrable effects. Because of the loca¬ 
tion of the gland, most of the operated animals die within twenty-four 
hours of hemorrhage, brain injury, and shock. But the few that survive 
the operation trauma are said to remain normal. Both Sarteschi and 
Foa report very different results from pinealectomy in young chicks, 
rabbits, and rats. According to Foa the operation has little or no effect 
in females, except a temporary retardation of growth. In the males the 
extirpation of the gland leads to precocious sexual maturity. This ac¬ 
celeration of sexual maturity was also observed by Sarteschi in operated 
male pups and rabbits. Horrax reported a slight acceleration of the 
growth of the testes in pinealectomized guinea pigs. No demonstrable ef¬ 
fects were produced in the operated females. The most important and 
conclusive work in pineal-gland extirpation is that recently reported by 
Dandy on young dogs. Dandy extirpated the pineal body in pups (male 
and female) ten days to three weeks old and observed their body growth, 
sex life, and mental behavior for eight to fifteen months after the opera¬ 
tion. In no case did he find sexual precocity or indolence, adiposity or 
emaciation, somatic or mental precocity or retardation. Dandy concludes 
that “the pineal body is not essential to life and seems to have no influence 
on the animals’ well-being at any age.” 

Feeding Pineal Material.—McCord reported that feeding pineal 
glands to . young animals (guinea pigs) accelerates growth and hastens 
sexual maturity, both in males and females. There was no tendency to 
gigantism. The pineal-fed animals simply attain adult stature at an 
earlier period. According to McCord, these effects are most striking when 
the pineal organ obtained from young animals (calves) is fed. Hoskins 
and also Sisson and Finney, on the other hand, obtained negative results 
from feeding pineal material to rats. McCord and Allen reported a 
peculiar contraction of the skin pigment in tadpoles fed with pineal ma¬ 
terial. They propose this reaction as a quantitative test of pineal extracts. 
Pineal substance seems to hasten reproduction in some unicellular 
organisms. 

Dana and Berkeley claim that feeding or injecting pineal gland to 
“backward” children improved their mentality, although growth of the 


764 


ORGANOTHERAPEUTICS 


body was not accelerated. Goddard and Cornell extended these tests to a 
large number of backward children. The results were negative. 

Pineal Tumors.—Tumors of the pineal body in the young have fre¬ 
quently been associated with acceleration of growth (mental and physical, 
including precocious adolescence). The syndrome is designated “macro- 
genitosomia-preecox.” Cachexia is present, probably due to brain injuries. 

The interpretation of the body changes in the case of pineal tumors 
in the sense of hypo-activity or hyperactivity of the gland is very un¬ 
certain, especially in view of the contradictory results of animal experi¬ 
ments. McCord reporting that pineal feeding produces the identical re¬ 
sults described by Foa and Sarteschi as following complete extirpation of 
the pineal body. 

There is, at present, no rational or useful pineal organotherapy. The 
contradictory effects reported from work on animals and the uncertainty 
of pineal deficiency in man must be cleared up before we are justified in 
trying pineal organotherapy in the clinics, even experimentally. At pres¬ 
ent, there is no reliable evidence that the pineal body is a gland, or a 
gland of any importance. The bodily changes in cases of pineal tumors 
may be due to involvement of the midbrain. 


THE THYMUS 

Physiology.—The thymus develops in the embryo from the epithelium 
of the third branchial pouch. Its origin is thus similar to that of the 
thyroid and the parathyroid. We have seen that accessory thyroids and 
parathyroids are frequently found embedded in the thymus tissue. The 
thymus is primarily an organ of fetal and preadolescent life, as in normal 
men and animals it undergoes involution at puberty, and is finally replaced 
by connective tissue, lymphoid tissue, and fat. But it is reported that the 
thymus of birds does not undergo involution at sexual maturity (Soli). 
Jansen reports “accidental involution” of the thymus in starvation and 
malnutrition. This is probably not a true involution but merely the great 
reduction in weight suffered by this organ is fasting. The relative size of 
the thymus is greatest shortly after birth. 

The thymus contains several types of cells. The outer or cortical por¬ 
tion of the gland is made up of lymphoid cells. According to Danschakoff, 
Hammar and others, these small cells of the thymus cortex differentiate 
into the various forms of leukocytes of the blood and lymph. Hoskins 
has pointed out the parallel between the decreasing percentage of weight 
of the thymus in relation to body weight, and the decrease in lymphocytes 
in the blood from birth to adolescence. The central portion, or medulla, 
is composed of a few lymphoid cells and the peculiar “corpuscles of 


THE THYMUS 


765 


Hassall, composed of nests of epithelial cells. The function of the 
HassalFs bodies is not known. 

The specific role of the thymus is still very obscure, and most of the 
investigators question whether it should be classed with the endocrine 
glands. The organ is not necessary for life. The facts definitely estab¬ 
lished are: the involution of the organ at puberty, and the delay of this 
involution by castration. 

Henderson states that early castration accelerates the growth of the 
thymus and prolongs or delays involution. Involution of the thymus oc¬ 
curred especially rapidly in animals used for breeding purposes. On the 



Fig. 22—Chart Showing the Weight of the Thymus of the Albino Rat According 
to Age. The observed weights are represented by 229 males and 207 females. 
(Hatai.) 


other hand, Paton states that removal of the thymus in sexually immature 
animals led to a rapid growth of the testicles. 

From such experiments and observations it has been concluded that 
the thymus exerts an inhibitory action upon the development of the testes; 
and that the development of the testes has an accelerating effect upon the 
involution of the thymus. Paton concludes from more recent experiments 
that thymus and testes both exercise an influence on the growth of the 
sexually immature animal; the removal of both retards growth. This has 
not been established for the ovaries and thymus of the female. After 
removal of one the other can compensate for its loss, and in doing so 
may undergo a more rapid growth, or, in the case of the thymus, may 
persist for a longer period. Further evidence of a relation between the 

























































































766 


OKGAN OTHERAPEUTICS 


thymus and sex glands has been sought in the fact that the ovaries are 
sometimes enlarged in status lymphaticus (Bartel and Herrmann). 

The relation of the thymus to growth was studied by Basch and others 
in young animals from which the thymus was removed. Such animals are 
said to show delayed growth and diminished intelligence. The changes 
in the bones were especially marked; these showed deficient ossification. 
Basch, and Paton also, reported that the peripheral nervous system showed 
an increased excitability, as determined by galvanic stimulation, and Paton 
suggests that there is a close relation of the thymus and the parathyroid 
functions. 

Klose and also Klose and Vogt state that if the thymus is removed from 
puppies about ten days after birth, there is a latent period of two to four 
weeks, followed by a condition of adiposity for two to three months, then 
cachexia and a condition resembling idiocy, and death in “thymic coma” 
after three to fourteen months. They say that extirpation of the thymus 
in infants is followed by similar results. They consider the gland to be 
an important organ in early life. They also state that the bones of ani¬ 
mals deprived of the thymus have only about half the normal amount of 
calcium. They consider the bone and other changes to be due to acid 
intoxication, and that one of the functions of the thymus is to inhibit the 
formation of or to neutralize an excessive formation of acids, probably 
nucleic acid. Essentially similar results were reported by Matti. 

But Nordmann states the removal of the thymus shortly after birth 
in dogs has no effect on growth or other physical conditions. Hammar 
found that thymectomy in frogs produced no demonstrable effects, and 
Allen has shown that thymectomy in amphibian tadpoles is without in¬ 
fluence on growth and metamorphosis. Morgulis and Gies report that the 
calcium content of the bones and teeth of thymectomized rats remained 
the same as in the normal controls; hence, they contend that the thymus 
has no definite necessary influence on bone growth. More recently ex¬ 
tensive and careful studies on thymectomy in rats and young dogs have 
been reported by Pappenheimer, Park, and Park and McClure. The re¬ 
sults were negative. 

The experimental results from thymectomy are, therefore, very con¬ 
tradictory. Koenig reports a resection of the thymus in a nine-months- 
old child, followed by severe and prolonged rachitis. There is no evidence, 
however, that the thymus resection was the cause of the rachitis. 

The thymus is often found persistent or enlarged in cases of Graves’ 
disease, especially in the severer forms. Capelle and Bayer believe that 
an internal secretion of the thymus aggravates the symptoms, especially 
the cardiac symptoms of the disease. They, as well as Pribram, report 
improvement from thymectomy. Bircher stated that the implantation into 
animals of a pathological thymus caused symptoms of Graves’ disease, 
such as tachycardia and tremors. 


THE THYMUS 


767 


Rachford believes that the thymus produces an internal secretion af¬ 
fecting nutritional processes, especially in fetal life and early childhood; 
he believes that status lymphaticus is due to an excessive activity of the 
thymus. Friedlander stated that exposure of the thymus to Roentgen rays 
causes diminution in the size of the spleen and lymph-nodes in status 
lymphaticus. Nordmann thinks that some cases of toxic goiter are due 
to abnormal functioning (hyperplasia) of the thymus. But feeding 
thymus to cretin rabbits is without effect (Carlson)/ 

Gudernatsch and Laufberger found that feeding thymus accelerates 
growth of frog tadpoles. This has been denied or ascribed to the food 
as such (Uhlenhutli). Shimizu claims to have produced a thymotoxic 
serum (thymolysis), the injection of which produces the same results as 
thymectomy. Ott and Scott report that thymus extracts have a galacta- 
gogue action. This is erroneous. Uhlenhuth reports that feeding calves’ 
thymus to salamander tadpoles induces tetany, and inhibits metamorphosis. 
He interprets this as establishing an internal secretion (toxic) by the 
thymus, this secretion being destroyed by the parathyroids. This in¬ 
terpretation seems at present far-fetched. Subcutaneous injections of 
thymus substance into young rabbits seem to produce no specific effects 
(Downs and Eddy). 

Pathology.—The primary role of the thymus, in the disease syndromes 
frequently associated with an enlarged thymus (status lymphaticus, thymic 
death, toxic goiter), is still unknown. There is no clear evidence that 
hyperfunction of the thymus is an etiologic factor, although the apparent 
beneficial effects of X-ray and surgery of the thymus may be so inter¬ 
preted. Mors thymica is not due to mechanical interference with cir¬ 
culation and respiration (Hammar). Stammering has been ascribed to 
hyperthymism (Browning). Bergstrand has described two cases of simul¬ 
taneous thymic and parathyroid hyperplasia. 

Therapeutic Uses of Thymus Extracts.—Thymus has been adminis¬ 
tered in many diseases (gout, simple and toxic goiter, marasmus, retarded 
growth, infantilism, rheumatism, arthritis, chlorosis, acromegalia, Addi¬ 
son’s disease, etc.). Mikulicz reports favorable results from thymus feed¬ 
ing in simple and toxic goiter. Uncertain or negative results from the 
administration of thymus in goiter (simple and toxic) were reported by 
Mackenzie, White, Parker, and many others. But thymus feeding has no 
effects on experimental hypothyroidism (rabbits), where all conditions 
can be controlled. 

Nathan administered thymus to rachitic children in doses of from two 
to four “five-grain” tablets (each tablet apparently containing dry gland 
equivalent to five grains of the fresh gland) three times a day for long 
periods. In one hundred and eighty-six cases treated, practically all im¬ 
proved. “When the thymus is conscientiously taken for a long period, and 
the patient is otherwise judiciously handled , marked improvement, if not a 


768 


ORGANOTHERAPEUTICS 


perfect cure, can always be expected.” “The otherwise judicious handling” 
of the patients was probably more important in the recoveries than the 
thymus feeding. In view of what we now know of the influence of light, 
foods, general hygiene, etc., on the 'prevention and cure of rickets, the treat¬ 
ment of this disease by thymus extracts seems preposterous. 

Favorable results (delayed growth and relief of pain) have been re¬ 
ported from the use of thymus in carcinoma! Gwyer administered it by 
the mouth in doses of thirty to one hundred and twenty grains (2.0 to 
8.0) of the dried powder three or four times a day in goiter, arteriosclero¬ 
sis, rheumatoid arthritis, hemorrhoids, cystic tumor of breast, pulmonary 
tuberculosis, and cancer! Haneborg reports good results from thymus 
feeding in chorea! 

Summary 

There is, at present, no rational or useful organotherapy of the 
thymus. The empirical and experimental thymus therapy of the past 
has not added to medical knowledge or contributed to the control of dis¬ 
ease, as none of the maladies in which thymus treatment has been tried 
has been shown to be related to thymic hypofunction or dysfunction. No 
specific thymus secretion or hormone is so far indicated by experimental 
and clinical work. 

In view of the apparent antagonism of the thymus to the testes, thymus 
therapy might prove useful in cases of sexual precocity and hvpergeni- 
talism due to gonad hyperplasia. It might also be possible to induce 
involution in cases of “persistent thymus,” or thymus hyperplasia by 
gonad therapy. But the Roentgen rays have proved very efficient in such 
cases. 


THE SPLEEN 

Physiology.—The specific functions of the spleen are as yet largely 
an open question. In the embryo the spleen forms red blood-corpuscles, 
but after birth or in the adult it seems to be concerned, directly or in¬ 
directly, with the destruction of erythrocytes. The spleen, like the liver, 
contains enzymes which convert the nucleins into uric acid. It is def¬ 
initely established that the spleen takes part in the fixation of antigens 
and in the production of immune bodies (Luckhardt and Becht). The 
immune bodies are internal secretions. But the decrease in the im¬ 
munity reaction after splenectomy is not great enough to be of practical 
significance. Specific relations of the spleen to the pancreas, the stomach 
and the liver have been suggested by a number of workers. Asher thinks 
that the spleen yields a kinase or activator to the liver. Lombroso and 
Manetti report increase in pancreas secretion after splenectomy. It has 


THE SPLEEN 


769 


also been stated that the secretion of the ferments of the pancreatic juice 
is decreased m the absence of the spleen. But the recent work of Inlow 
goes to show that splenectomy has no effect on the gastric and pancreatic 
secretions. There is enlargement of the spleen and other lymphoid tis¬ 
sue in severe infections and a very great decrease in the weight of the 
spleen in starvation, and after ligation of the pancreatic ducts (Sweet and 
Ellis), hut there is no evidence of any specific influence of the spleen 
on metabolism. One fact is definitely established: whatever the func¬ 
tions of the spleen, they are not specific, for the removal of the spleen 
does not seriously impair health or growth, nor does it shorten the span 
of life. (Henn). 

Effects of Splenectomy in Normal Animals and Persons.— This prob¬ 
lem has in late years been extensively investigated by Pearce and his 
collaborators. In the dog splenectomy causes, as a rule, the transformation 
of the fatty marrow of the long bones into a richly cellular red marrow 
(Pearce and Pepper). It is not followed hy any marked disturbance in 
nitrogen or fat metabolism or in iron elimination unless followed by 
severe anemia (Goldschmidt and Pearce). Raw foods, especially meat, 
diminish the temporary anemia of splenectomy in normal animals. The 
temporary anemia (two to three months) is associated with an increased 
output of iron in the feces, indicating a temporary decrease in the power 
of the body to conserve the iron of the decomposed hemoglobin, rather 
than an increased destruction of erythrocytes. The anemia is not due 
to lack of iron in the body (Pearce, Austin and Pepper), and it should 
be noted that in some animals (dogs) there is no temporary anemia fol¬ 
lowing splenectomy. 

Soper reports an increase of the cholesterol of the blood after splenec¬ 
tomy. The reports on the influence of splenectomy on the resistance of 
the red blood-corpuscles to laking are conflicting, but most workers state 
that splenectomy increases the resistance. According to Donati, splenec¬ 
tomy increases the permeability of the erythrocytes to glucose. Removal 
of the spleen in mice is said to increase their resistance to tuberculosis, 
and feeding fresh spleen to mice to lower the resistance (Lewis and Mar¬ 
got). This seems questionable. 

Experimental Administration of Spleen and Spleen Extracts.— Dan- 
ilewsky, Silvestri and Krumbhaar and Musser state that subcutaneous 
or intraperitoneal injections of spleen extracts in animals (dogs) cause 
a sharp rise in the number of erythrocytes and in the percentage of 
hemoglobin. This rise lasts but one or two days and may be followed by 
an equally temporary drop of the erythrocytes below the normal number. 
It is claimed that extracts of other organs, similarly administered, fail 
to give this effect on the blood. Hence, it appears to be specific for the 
spleen tissue. But others have reported a temporary increase in erythro¬ 
cytes and leukocytes after administration of tonsil and lymph-gland ex- 


770 


ORGAKOTHERAPEUTICS 


tracts. The injection of the spleen extract has no influence on the re¬ 
sistance of the red cells to hemolysis. In some cases the administration 
of the spleen extract induced a slight and temporary leukocytosis, but this 
was also noted in the case of extracts of other organs. Krumbhaar and 
Musser noted that the constant increase in red cells in the peripheral 
circulation after injection of spleen, in view of the tendency to anemia 
following splenectomy, suggests that “the spleen may normally exert a 
stimulating effect upon the formation of red cells in the bone mar¬ 
row.” 

Feeding spleen or spleen extracts to animals, even over a long period, 
has no effect on the blood picture, and fails to prevent or diminish the 
anemia following splenectomy (Krumbhaar and Musser). This is a fact 
of great practical importance for possible spleen organotherapy in man, 
where repeated subcutaneous or intraperitoneal administration of a crude 
tissue extract is, of course, out of the question. We see that on the basis 
of well-controlled animal experiments we cannot hope to control spleen 
deficiency or induce specific spleen functions by feeding spleen or spleen 
preparations. 

Flexner has reported various toxic effects from spleen extract admin¬ 
istration. 

Hypofunction or Dysfunction of Spleen in Splenic Anemia Hemolytic 
Jaundice, and Hanot’s Cirrhosis. —There is some destruction of erythro¬ 
cytes in the normal spleen, and possibly some degree of control by the 
spleen of red marrow, blood plasma, and erythrocytes so that the rate of 
erythrocyte production and hemolysis strike a balance in the normal ani¬ 
mal. In splenic anemia and hemolytic jaundice there is usually enlarge¬ 
ment of the spleen, a decrease of resistance of the erythrocytes to hemo¬ 
lysis, and an actual increased rate of erythrocyte destruction, as shown 
by the output of urobilinogen, urobilin, and iron in the feces. McKelvie 
and Rosenbloom report a case of hemolytic jaundice and splenomegaly with 
the erythrocytes showing a decreased resistance to hypotonic laking. The 
suggestion is made that this may be due to a decrease in the cholesterol 
content of the blood. Robertson states that in pernicious anemia the 
erythrocytes of the splenic vein show less resistance to laking agents than 
those of the general circulation. Extracts of the normal spleen have, how¬ 
ever, no hemolytic action in vitro (Krumbhaar and Musser). This is also 
true of spleen extracts from pernicious anemia patients (Robertson). Ex¬ 
tirpation of the spleen in splenic anemia appears to restore such patients 
to normal health, either through the absence of the actual hemolysis taking 
place in the spleen, or to some increased resistance in the erythrocytes to 
laking agents in the blood itself. 

After an examination of all the cases so far reported Miller con¬ 
cludes that “splenectomy is undoubtedly curative.” Gerdes does not ap¬ 
pear to be so sure of this. But the improvement following splenectomy 


THE SPLEEN 


771 


shows clearly that the hyperfunction or dysfunction of the spleen is the 
primary cause of this type of anemia. 

The Spleen in Pernicious Anemia.— The relation of the spleen func¬ 
tion to pernicious anemia is less definitely established. Most observers 
agiee that splenectomy in pernicious anemia usually induces a temporary 
stimulation of the blood-forming organs, and, hence, a transient improve¬ 
ment of the anemic condition, but “in no case can it be said that the 
splenectomy produces a. cure of the disease” (Krumbhaar). Blood trans¬ 
fusion has a similar stimulating action, but less marked and somewhat 
more transitory (McClure, Lee, Minot and Vincent). There is, then, no 
evidence that the spleen functions are primarily concerned in pernicious 
anemia. 

There is no satisfactory explanation of the opposite effects on the 
blood of splenectomy in normal persons and animals ( temporary anemia) 
and in patients with pernicious anemia ( temporary improvement of the 
blood). 

Therapeutic Uses of Spleen and Spleen Extracts. —The use of spleen 
extracts in constipation and intestinal stasis as a specific stimulant to 
gastro-intestinal movements (Zuelzer) is referred to in the section on Duo¬ 
denal Mucosa. 

Spleen extracts have also been used in anemia and chlorosis, in ma¬ 
laria, in menorrhagia, and in hemophilia. No reliance can be placed on 
the favorable results sometimes noted in these maladies, in view of recent 
work on the relation of spleen to anemia, and the further fact that spleen 
and spleen extracts given by mouth have no specific action on the organ¬ 
ism. The anemias that are benefited by organic iron preparations will, 
naturally, show improvement on spleen therapy, as the spleen is rich in 
iron. But this is drug or food therapy, not organotherapy, as this action 
is not specific for the spleen. 

The most strikingly irrational use of any organ or organ extract in 
therapeutics seems to be that of spleen extract in tuberculosis. Harrower 
and others have advocated and claimed to have proved that feeding spleen 
is a specific in tuberculosis! There is no basis for such therapy of tu¬ 
berculosis either in the physiology and pathology of the spleen, in the 
biology of the tubercle bacillus or in the natural history of tubercular 
infections. As a matter of fact, Lewis and Margot state that splenectomy 
in mice increases the resistance to tuberculosis, while feeding spleen has 
the opposite effect. 


Summary 

There is, at present, no evidence that the spleen secretes or stores 
hormones, or that hypo function of the spleen causes disease; hence there 
is no rational or useful organotherapy of the spleen. 


772 


ORGANOTHERAPEUTICS 


THE GASTRIC AND DUODENAL MUCOSA 

Secretins. —It is well established that acids or acid chyme in the 
duodenum is a stimulus to the secretion of pancreatic juice and bile. 
Bayliss and Starling macerated duodenojejunal mucosa in 0.4 per cent 
hydrochloric acid, neutralized the mixture, and filtered. A few cubic 
centimeters of the filtrate injected into a vein invariably produced secre¬ 
tion of pancreatic juice. The substance in the extract stimulating the 
pancreas was called “secretin.” The secretin has since been prepared 
by other methods, and from a variety of plant and animal tissues. It is, 
thus, not specific for the duodenojejunal mucosa. It has not been prepared 
in pure state. All secretin preparations seem to have vasodilator actions. 
Popielski attributed the action on the pancreas to the vasodilatation. This 
is probably not the primary or essential factor. Luckhardt has shown 
that the “secretin” of Bayliss and Starling is probably an artefact or 
drug rather than a physiologic agent, as this secretin on hypodermatic 
injection stimulates the pancreas and the gastric glands, while acid in the 
duodenum stimulates the pancreas promptly and the stomach not at all, or 
after a latent period of thirty to sixty minutes. Furthermore, prolonged 
action of acid in the duodenum finally fails to stimulate the pancreas. 
This is not due to fatigue of the pancreas itself, nor to exhaustion of 
the duodenal mucosa, for this mucosa on acid extraction yields as much 
“secretin” as the resting mucosa. It is therefore clear that if there is 
a hormone or “secretin” mechanism connecting the pancreas and the duo¬ 
denum, this hormone (secretin) has not yet been extracted from the duo¬ 
denal mucosa. The simplest explanation of the stimulation of the pan¬ 
creas by acids in the duodenum would be a local nervous reflex, but that 
this does not account for it completely seems to be shown by the de- 
nervated intestinal loop experiments of Bayliss and Starling, as well as 
by the even more crucial transfusion experiments (Wertheimer, Hen- 
riquez and Hallion), and of cross circulation (Fleig, Matuso). 

To the extent that the secretin passes into the lumen of the gut it 
is a wasted secretion and is quickly destroyed by trypsin and by pepsin 
hydrochloric acid digestion, and, even in the absence of these digestive 
ferments, secretin is not absorbed in active form from any part of the gut. 
Giving secretin by mouth is therefore without effect on the activity of 
the pancreas and the liver. Subcutaneous injections of secretin are also 
practically without effects. In consequence of the instability of secretin 
the commercial preparations of secretin so far placed on the market (se- 
cretogen, duodenin, also the secretin of Beveridge) contain, as a rule, no 
prosecretin or active secretin (Carlson, Lebensohn, and Pearlman). 

Secretin has not yet been prepared in pure form. It represents at 
present a mixture of substances, probably including cholin. Repeated 


THE GASTRIC AND DUODENAL MUCOSA 773 

intravenous injections of secretin are, therefore, highly toxic, producing 
collapse (Starling). r 

Secretin Organotherapy. —It is obvious that a rational and useful 
secretin therapy demands these two fundamental conditions: (1) Secretin 
must be a normal or physiological substance and deficiency of secretin in 
the duodenal mucosa must be an important factor in the etiology of the 
disease . (2) Secretin must be able to influence the pancreas and the liver 

when given by mouth, for it is not safe to introduce it repeatedly into the 
veins of human beings. Neither of these two conditions has been estab- 



Fig. 23.—Tracings Showing Practically Complete Destruction of Secretin by the 
Gastric Juice. Dog under light ether anesthesia; cannula in the pancreatic duct; 
a, carotid blood-pressure; 6, record of flow of pancreatic juice in drops. Time, 25 
minutes. Tracing A: intravenous injection of 10 cubic centimeters secretin (pre¬ 
pared fresh from dog’s duodenal mucosa) at x. Tracing B: intravenous injection 
(at x ) of 10 cubic centimeters of the same secretin as in Tracing A, after being 
digested in normal human gastric juice at 37 C. for 2 hours. (Carlson, Lebensohn 
and Pearlman.) 


lished. Despite this, secretin, or alleged secretin, has been used in the 
therapy of a variety of diseases. 

Diabetes Mellitus. —Moore, Edie and Abram were the first to suggest 
a therapeutic value for secretin, having obtained favorable results with 
secretin administration in diabetes. They argued that the internal secre¬ 
tion of the pancreas may be stimulated by secretin, and that some cases 
of diabetes may be due to lack of this necessary excitant. Owing to the 
importance of the question, their announcement was followed quickly by 
numerous investigations by other observers. 

Previously, Spriggs, at the suggestion of Starling, had tried intra¬ 
venous injections of secretin, free from depressor substance in a diabetic 
patient, and had obtained negative results. Moore, Edie and Abram gave 
their secretin by mouth over long periods. Of the five cases cited in 






774 


ORGANOTHERAPEUTICS 


their first paper, two were negative. The third was that of a man aged 
twenty-five, who received daily 30 c.c. of secretin; after a latent period of 
three weeks, the sugar suddenly fell, and after four months the urine was 
sugar-free. Six months later a relapse occurred with the development of 
phthisis and death. The other two patients were a hoy aged seven, and a 
girl aged nine, whose urine in from three to five weeks became sugar-free, 
during secretin treatment, in spite of severe diabetes. One of these pa¬ 
tients later relapsed. Bainbridge and Beddard gave secretin a thorough 
trial in three cases with negative results, and are disposed to attribute the 
results of Moore to dieting. Dakin and Ransom cited one case, secretin 
being given for twelve weeks, with negative results; Foster, nine cases, all 
negative; Charles, three cases, all negative. Moore, Edie and Abram, in a 
later paper, report a large number of cases tried with the majority of 
results negative, though in some cases an improvement in the digestion, 
and in certain cases an increase of weight, was noted. 

One method of testing the basis of Moore’s theory would be by ex¬ 
amining the prosecretin content of the intestine in diabetes. Bainbridge 
and Beddard found, in the paper referred to, that from five of the six 
cases of diabetes examined postmortem, little or no secretin could be pre¬ 
pared, but in a subsequent report, of seven cases they found only one in 
which the secretin obtained was scanty. The failure to obtain secretin 
in some cases they claim is probably due to the rapid postmortem degenera¬ 
tion of diabetic tissue. Evans, in Starling’s laboratory, stated that in 
dogs made recently diabetic by total pancreatectomy, but little secretin 
could be obtained. Hedon and Lisbonne, and Pemberton and Sweet, re¬ 
port, on the contrary, that the duodenum of diabetic dogs is rich in pro¬ 
secretin. Bainbridge and Beddard, working on a diabetic cat, likewise 
found prosecretin to be present in normal quantity. 

Digestive Disturbances. —Enriquez has proposed that deficiency of 
secretin is a factor in intestinal indigestion and in constipation. This is 
pure guess. Beveridge reports the use of secretin in pyloric stenosis, pan¬ 
creatic insufficiency, cirrhosis of the liver, colonic stasis, in gastro-enteros- 
tomy and short-circuiting of the intestines. Harrower advocated the use 
of secretin for a large number of maladies. 

Alleged Gastro-intestinal Motor Hormone of Mucosa; “Hormonal”; 
Cholin. —Heidenhain showed more than twenty-five years ago that intra¬ 
venous injections of tissue extracts cause a temporary intestinal peristalsis, 
defecation, vomiting, etc., probably due to asphyxia from the greatly 
lowered blood-pressure, besides a number of other untoward symptoms. 
In 1904, Henriquez and Hallion showed that by treatment of strips of 
gut with Ringer’s solution or distilled water a substance may be extracted 
which stimulates contractions in another intestinal strip. 

Similar results were observed when the extract was injected into nor¬ 
mal intact animals. This stimulating action is prevented by atropin. 


THE GASTRIC AND DUODENAL MUCOSA 


775 


In 1908, Zuelzer proposed, on the basis of badly controlled animal experi¬ 
ments, the novel theory that there is a specific gastro-intestinal motor 
hormone, elaborated in the intestinal mucosa during digestion, absorbed 
into the blood and stored in the spleen. Hence, the spleen was held to 
contain more of this alleged hormone than any of the other organs. It 
was claimed that an extract of spleen and intestinal mucosa (“hormonal”) 
on intravenous or intramuscular injection produces normal intestinal 
peristalsis in man and animals without any injurious side effects. The 
extract was tried for a time, especially in Germany, in cases of chronic 
constipation, and postoperative intestinal stasis. It was soon found that 
intravenous injections of this extract in patients may cause shock, col¬ 
lapse and sudden death. And the more carefully controlled investigations 
of Dittler and Mohr, Sabatowski, Schlagenweit and others showed that 
intramuscular injections of the extract have little or no action on gastro¬ 
intestinal motility, while the intravenous injections produce the general 
toxic symptoms characteristic of all tissue extracts. Hence, there is 
no specific or physiological motor hormone in the duodenal and spleen 
extracts. 

After careful perusal of the entire “hormonal” literature, we are 
impressed with the uniformly favorable results first reported by Zuelzer 
and a host of other clinicians in two important cases, namely, chronic 
constipation and postoperative intestinal stasis. These results were un¬ 
doubtedly due to suggestion and dictated by uncritical enthusiasm, faith, 
and hope in a new remedy. When crucial judgment returned, “hormonal” 
was speedily found not only wanting but dangerous. The “hormonal” 
therapy had no basis in physiology or pathology. It was not based on 
well-controlled experiments on animals. So after a brief popularity with 
the credulous clinician, it passed naturally to the therapeutic bone yard. 
“Hormonal” cannot do anything with gastro-intestinal motility that can¬ 
not be accomplished, and with greater safety, by such drugs as pituitrin, 
pilocarpin, or eserin. 

In a recent series of investigations, Le Heux has advanced the theory 
that cholin in the wall of the gut constitutes the motor hormone for 
gastro-intestinal peristalsis. This view is accepted by Magnus. But 
cholin is a constituent or cleavage product of the phosphatids of all ani¬ 
mal tissues. Cholin in the blood is increased in cases of degenerating 
nervous tissues, but there is no evidence that this is accompanied by in¬ 
testinal hyperperistalsis. Kiihlwein has shown specifically that the in¬ 
testinal stasis during and following anesthesia is not accompanied by a 
decrease of cholin in the intestinal wall. 

At present, it is neither safe nor expedient to use a toxic substance 
like cholin, hypodermatically, to control motor paralysis of the gut 

Other Possible Hormone Functions of Intestinal Mucosa.— The work 
of Draper and of Whipple and his collaborators on duodenal extirpation 


776 


ORGANOTHERAPEUTICS 


and duodenal obstruction has suggested hormone functions of the duo¬ 
denal mucosa other than those concerned with secretin and enterokinase. 
Matthews claims that extirpation of the upper part of the duodenum in 
the dog invariably leads to death within three days; hence, he concludes 
that the duodenum is as necessary for life as the adrenals or the para¬ 
thyroids, presumably through hormone function. But others have dem¬ 
onstrated that animals live indefinitely after duodenal extirpation (Min¬ 
kowski, Dragstedt, Moorehead, Mann). Draper reports that feeding 
duodenal mucosa to dogs with duodenal obstruction or a closed duodenal 
loop lengthens the life of the animal somewhat, but fails to prevent death. 
These experiments by Draper are not convincing. Whipple reports the 
secretion or production of a toxic substance (protein-split product) in 
closed intestinal loops, and successful immunization of dogs against this 
toxin. Dragstedt and his coworkers have demonstrated that the toxins of 
intestinal obstruction or closed intestinal loops are developed by the putre¬ 
factive bacteria acting on the food and secretion proteins in the gut. 
The experimental work so far has yielded nothing in the way of hints of 
useful duodenal mucosa organotherapy of intestinal stasis and intestinal 
obstruction. 

The Gastric Mucosa; Gastrin. —Shortly after the work of Bayliss and 
Starling on pancreatic secretion, Elkins, by analogous experiments on the 
stomach, developed the theory that acids in the food, or the acid of the 
gastric juice acting on the mucosa of the pyloric end of the stomach, pro¬ 
duce or hibernate a specific secretagogue '(“gastrin”) in the blood, which 
activates the fundic glands. It has since been shown by a number of 
investigators that an active “gastrin” can be prepared by acid extrac¬ 
tions, not only from the gastric mucosa, but from the mucosa of the en¬ 
tire alimentary tract, from the liver, the thyroid, various plant tissues, etc. 
“Gastrin” is not specific since it stimulates both the gastric glands and 
the pancreas. It has no effect when given by mouth. “Gastrin” is evi¬ 
dently an artefact, not a physiological mechanism. Koch, Luckhardt and 
Keeton have shown that it is similar to but not identical with histamin 
and pilocarpin. 

The experimental work on the “gastrins” has led a drug manufacturer 
to put gastric mucosa preparations (“gastron”) on the market buttressed ' 
by unproved, if not impossible, claims. The “gastrins” may some day 
be so purified that they may be injected hypodermatically in man, 
without injury, to increase gastric secretion. But this is drug action, 
not organotherapy. Given by mouth, gastric mucosa or gastrin prepara¬ 
tions are without effect except when given in such large quantities that the 
dose practically amounts to a serving of soup. The doctor who uses such 
preparations cheats the patient and deceives himself, unless he uses them 
as vehicles for suggestion, in which case a pill or a capsule containing an 
equally harmless but less expensive stuff will do as well. 


THE BLOOD 


777 


Summary 

1. The substances “gastrin” and “secretin'" are drugs, not physi¬ 
ological mechanisms or hormones. They are ineffective when administered 
;per os, and cannot with safety he given parenterally. 

2. The gastric and duodenal mucosa may produce hormones that 
specifically regulate the activity of the pancreas, the gastric glands and 
intestinal motility. These hypothetical hormones have not yet been ob¬ 
tained in extracts of these organs, nor has it been shown that deficiency 
of these hormones produces a disease. 

3. We have, therefore, no rational or useful organotherapy of the 
gastro-intestinal mucosa . 


THE BLOOD 

Blood Transfusion. —The normal blood contains all the substances 
(nutrients, enzymes, hormones, immune bodies, etc.) necessary for the 
proper functions of all the organs, so far as these are exchanges between 
the tissues. Theoretically it ought to be possible to administer all hor¬ 
mones to a patient by the transfusion of normal blood; but experiments 
have shown that the hormones of the thyroid, the pancreas, the adrenal, 
the parathyroid are present in the normal blood in such infinitesimal 
traces or are so quickly destroyed and used up that blood transfusion in 
cases of hormone deficiency has proved of no practical value. Another 
reason for the failure of transfusion as a general hormone therapy is the 
difficulty of transferring enough of the normal blood to the patient, with¬ 
out previously draining the patient of the greater part of his own blood, 
and without endangering the donor. The 300 to 600 c.c. usually trans¬ 
ferred in blood transfusion of adults is too small a percentage of the total 
blood. 

Considering blood as a tissue or organ, blood transfusion is virtually 
organ transplantation. The blood is the ideal organ for transplantation 
from the aspect of surgical technic, as there are no nervous and vascular 
connections to be considered, and, in compatible bloods, no destructive 
enzymes to be eliminated. But from the physiological aspect we can hope 
for less permanent results from transplantation of blood than in the case 
of any other organ. The equilibrium of the blood, both as to corpuscles 
and plasma constituents, is a dynamic, not a static, one, and depends on 
the activity of the other organs. The effects of blood transfusion are, 
therefore, necessarily temporary, and the most satisfactory results are ob¬ 
tained in case of temporary need, as in hemorrhage, carbon monoxid 

poisoning, etc . 


ORGANOTHERAPEUTICS 


Blood transfusion has also been tried, with no significant results, in 
various infections, with the idea of transfusing immune bodies and active 
phagocytes to the patient. It has been tried in hemophilia, purpura hem¬ 
orrhagica, etc. But the most extensive transfusion therapy so far de¬ 
veloped is that of the various anemias. Clinical and experimental experi¬ 
ence appear to agree that blood transfusion stimulates temporarily the 
blood-forming organs of the patient or the recipient, even in cases of 
pernicious anemia, unless the cachexia approaches that of a moribund 
condition. The transfusion is, therefore, of value as a temporary, pal¬ 
liative measure, not so much in virtue of the quantity of normal blood 
transferred as in the fact that this blood actually stimulates the patient’s 
own blood-forming organs to greater activity. In cases where the anemia 
appears to he due primarily to too rapid destruction of erythrocytes, we 
may expect blood transfusion to be of less benefit. 

Physiology and pathology give us no basis for expecting, and clinical 
experience has not shown, that anemia, except that due to actual me¬ 
chanical loss of blood, is cured by transfusion, especially where the condi¬ 
tion is hereditary or partakes of the nature of malignancy. 

Therapeutic Uses of Leukocytic Extracts. —Hiss and also Hiss and 
Zinsser, beginning in 1908, reported that intraperitoneal or subcutaneous 
injections of extracts of leukocytes in animals, and subcutaneous in¬ 
jections of the extract in human patients, protect against many infections 
(pneumococcus, staphylococcus, streptococcus, meningococcus, typhoid, 
dysentery, and cholera), and in patients hastens the recovery from these 
infections. Zinsser, McCoy and Chapin later reported a similar protec¬ 
tive action of leukocytic extract against experimental bubonic plague. 
Floyd and Lucas and also Lambert report good results from leukocytic 
extracts in pneumonia and erysipelas. On the other hand, Alexander 
observed no favorable results in any infection. Williams and Youland 
stated recently that leukocytic extracts have no effect on the temperature, 
the leukocyte count, the condition of the patients, or the course of the dis¬ 
ease in lobar pneumonia. Youland obtained practically negative results 
with the extracts of experimentally induced, acute infections in animals, 
thus contradicting the original observations of Hiss and Zinsser. 

Archibald and Moore report that injections of leukocytic extracts pro¬ 
duce a temporary leukocytosis in normal animals and normal persons as 
well as in patients with infectious diseases. They claim to have obtained 
good results, and report one case each of lobar pneumonia, cellulitis, 
puerperal sepsis, empyema, and erysipelas. The cases reported prove 
nothing definite as to the value of the extract injections. 

Archibald and Moore ascribe the favorable action of leukocytic ex¬ 
tracts to the stimulation of leukocytosis. Manewaring supports the view 
of a direct bactericidal action of the extract. Such bactericidal action can 
be demonstrated in vitro, but it is too slight to be of any significance when 


THE KIDNEY 


779 


a few cubic centimeters of the extract are injected subcutaneously into an 
adult person. It has also been alleged that leukocytic extracts increase 
the immunity reaction, and aid the action of specific serums, antitoxins, 
and vaccines. There is no evidence for this. 

Action of Leukocytic Extracts. —The action of these extracts in infec¬ 
tions is probably not specific. It is well known that the injection of any 
foreign protein or nucleoprotein produces in most cases a temporary fever 
and leukocytosis. To the extent that these two reactions are of value in 
infectious diseases, leukocytic extracts, other organ extracts, or, still better, 
simple proteins may have some effect. But this is drug action, not organo¬ 
therapy. 

The important role in immunity (phagocytosis, production of immune 
bodies) ascribed to the leukocytes by Metchnikoff is probably responsible 
for the great attention given to leukocytic extracts in infectious diseases. 
The leukocytes are not important elements in the fixation of antigens and 
production of immune bodies (Hektoen and Carlson). 

Hemoglobin Feeding. —The feeding of hemoglobin in various anemias 
is not organotherapy. There is no evidence that giving hemoglobin by 
mouth or parenterally stimulates the bone marrow or prolongs the life 
of the erythrocytes, except as this may be done by any other organic iron 
compound. 

Lymph-gland Therapy. —On the basis of incompetent experiments 
(hemodvnamic action following intravenous injection of extracts of the 
lymph glands) Marfori has postulated a hormone (“lymphogangline”) 
production by the lymph glands. After reviewing the entire literature 
on the subject Vincent concludes “that there is not the slightest reason 
for believing that the lymph glands carry out any endocrine function.” 

Summary 

There is, at present, no organotherapy of the hlood, of the individual 
blood constituents, or of the lymph glands. 


THE KIDNEY 

The theory that the kidneys produce a physiologically important in¬ 
ternal secretion, in addition to their excretory function, proposed by 
Brown-Sequard and d’Arsonval in 1893, has been shown repeatedly to be 
without foundation (Bradford, Suner, Vincent and Sheen Karsner 
Bunker, and Grabfield), but it still finds some adherents (Itakura). It 
has been claimed that ligation of the ureters does not produce the same 
effects on the animal as extirpation of the kidneys; and that the remova 
of the greater part of the kidney substance accelerates metabolism apart 


780 


ORGANOTHERAPEUTICS 


from or in the absence of uremia. None of these claims has been sub¬ 
stantiated. 

Itakura has recently advanced the novel view that the kidneys regu¬ 
late the concentration of the sugar in the blood by an internal secretion. 
This is unlikely, in view of the absence of primary renal involvement 
in diabetes, and the absence of hyperglycemia or reduced power to oxidize 
sugar in nephritis, except as due to uremia. 

Practically all the therapeutic uses of kidney extracts have been re¬ 
lated to conditions of impairment of the excretory functions of the kidney. 
Capitain, Donovan, Formanek and Eiselt, Renaut and others have re¬ 
ported the cure of nephritis and uremia by feeding kidney or subcutane¬ 
ous injections of kidney extracts. Others report negative or injurious 
effects (Lewandowsky, Senator). Kidney extracts have no specific di¬ 
uretic action; but kidney extracts for kidney organotherapy are on the 
market. Jauregg and Bayer listed (1914) seven German and one French 
commercial preparations. And here is a sample of the American clinical 
evidence for the efficiency of dried kidney substance in nephritis. “The 
woman was five months pregnant, the urine showed a low specific gravity, 
about 1 per cent albumin, and other indications of renal embarrassment. 
She was given renal compound (dried kidney and pancreas). After its 
use for two months , together vnth a regulated diet and rest, the urine 
showed a normal specific gravity and no albumin. I cannot help but feel 
that we owe a good deal to organotherapy’ 7 (Harrower). 6 

In the light of our present knowledge of kidney functions and kidney 
pathology, the treatment of uremia and nephritis by kidney extracts is 
useless, and possibly injurious. 


THE LIVER 

The liver plays a very complex part in the animal economy; external 
secretion (bile), detoxication (ammonia, amino-acids, hemoglobin, poisons, 
etc.) , internal secretion (glycogen, fibrinogen, antithrombin, immune 
bodies, etc.), desaturation of the fats, storage of vitamins, etc. So far 
as we know, all these processes depend from moment to moment on the 
living hepatic cells, and, as far as we know, there is stored up no sub¬ 
stance of the nature of a hormone in the liver cells. Hence, there is no 
rational basis for liver organotherapy. Nevertheless extracts of the liver 
have been administered (by mouth or subcutaneously) in cirrhosis, dia¬ 
betes, Banti’s disease, hemoptysis, purpura, epistaxis, hematemesis, me¬ 
trorrhagia, prurigo, urticaria, snake bite, and other affections! It appears 
that most of this irrational and certainly useless therapy has been ad- 


6 The italics are mine.—A. J. C. 




THERAPEUTIC USES OF OTHER ORGAN EXTRACTS 781 

vanced by European clinicians. Good results are reported, of course. 
Jauregg and Bayer ( Lehrbuch der Organotherapie) listed fourteen organo- 
therapeutic liver preparations on the market. -Eleven of these were 
“made in Germany”! 

There is, at present, no rational or useful organotherapy of the liver, 
and because of the nature of the liver functions there is little or no 
hope for the future in this direction. But biochemical research may pro¬ 
duce from the liver substances of biological and clinical importance in the 
way of drug actions. 

The recent work of Mann and others on extirpation of the liver indi¬ 
cates that the depression and death of the animal following loss of the 
liver is accompanied by extreme hypoglycemia. The depression can be 
temporarily controlled by intravenous injection of glucose, but the animal 
dies despite the glucose administration. The cause of this hypoglycemia 
is not known. The condition is not improved by liver extract adminis¬ 
tration. But Hooper has shown that feeding liver can partly control the 
digestive disturbance following the complete elimination of the bile from 
the digestive tract in dogs. 


THERAPEUTIC USES OF OTHER ORGAN EXTRACTS 


Brain and Spinal Cord. —The treatment of epilepsy, amentia, de¬ 
mentia prsecox, mania, melancholia, chorea, tetanus, hydrophobia, etc., 
with extracts of nervous tissue, is, in the light of our present knowledge, 
less rational than the principles and practices of Mrs. Eddy. The litera¬ 
ture on this therapy is abundant, contradictory and worthless. This is 
not saying that the nervous tissues produce or store no hormones, or 
that interesting and useful drugs may not be prepared from these tissues. 
But these things will never be established by indiscriminate feeding of 
dried brain to patients. Perhaps we would make greater progress if the 
manufacturers could be induced to use the brains.of horses instead of asses 
and sheep for their raw material, and the finished product was taken 

by the doctor instead of given to the patient. 

Bone Marrow. —The red marrow of the bones is an essential factor 
in the production of red corpuscles, and probably in the formation of 
many immune bodies. But there is no evidence that feeding or injec¬ 
tions of hone-marrow extracts is of any practical value m hone-marrow 


diseases 

” Tumors.— Rational basis for the treatment of malignant growths with 
tumor extracts has been sought in the principles of vaccination and the 
“protective ferments” of Abderhalden. The results are unreliable or 
negative (Schubert, Bauer, Lotzel and Wissley). 


782 


ORGANOTHERAPEUTICS 


Muscle. —Meat is a good food for most people in health and for some 
people in disease. But meat extracts are of no value as organotherapeutic 
agents. 

Lung, Parotid Gland, Tonsils, Lymph Glands, Retina, Iris, Nasal 
Mucous Membrane, Etc.— Why complete the list? Lung, parotid gland, 
tonsils, lymph glands, retina, iris, nasal mucous membrane, etc., have 
been used, in modem medicine , to cure diseases of these tissues. We are 
afraid this chapter furnishes an argument against evolution in medicine. 
It would be rare humor—if we were not dealing with human ills, and 
with a profession standing for intelligence and honesty, in opposition to 
the quacks. 

Summary 

The sum total of established facts after thirty years of clinical and 
experimental work in organotherapy are few and quickly stated. 

But a treatise on the general principles of organotherapy involves 
to-day, in a large measure, the disagreeable and thankless task of clearing 
away worthless and misleading rubbish. We believe that the reader who 
has had the interest and diligence to follow us through this chapter will 
agree to this proposition, and we have endeavored to do it on the basis 
of clinical and experimental facts and biological reasoning. 

In the greater task of pointing out new lines of possible advance and 
control, w r e have endeavored to steer a middle course between the Scylla 
of therapeutic nihilism, and the Charybdis of therapeutic credulity. 


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General 

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Abel. Mellon Lect., Univ. Pittsburg, 1918. 

Asher. Schweiz, med. Wchnschr., 1, 1053, 1920. 

Barker. Monographic Medicine, iv, 855, 1917. 

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Barker, Hoskins, et al . Endocrinology and Metabolism, i, 1922. 

Biedl. Innere Sekretion, Vienna, 1913. 

Block. N. Y. State Med. Journ., xvii, 125, 1917. 

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Carlson. Journ. Am. Med. Ass., lxxix, 98, 1922. 

Cobb. The Organs of Intern'ml Secretion, New York, 1917. 
Falta-Meyers. The Ductless Glandular Diseases, Philadelphia, 1916. 



REFERENCES 


783 


Fawcett, et al. Am. Journ. Physiol., xxxvii, 1915. 

Garrison. Pop. Sc. Month., lxxxv, lxxxvi, 92, 142, 531, 1914-1915. 
Gley. Secretion Internes, Paris, 1920. 

Halsey. Endocrinology and Metabolism, i, 81, 1922. 

Hare. Am. Journ. Obst., lxvi, 1912. 

Harrower. Practical Organotherapy, 1920. 

Henderson. Canad. Med. Ass. Journ., v, 661, 1905. 

Hoskins. Journ. Exper. Zool., xxi, 295, 1916. 

Jarvis. Med. & Surg. Journ., clxxi, 1914. 

Jauregg and Bayer, von. Lehrbuch der Organotherapie, Leipzig, 1914. 
Jones. Animal Extracts in Ophthalmology, Canad. Med. Ass. Journ., 
v, 678, 1915. 

Krehl-Beifeld. The Basis of Symptoms, Philadelphia, 1916. 

Larson. Am. Journ. Physiol., xlix, 55 , 1919. 

Loeb, L. Journ. Med. Research, xl, 477, 1919. 

Lorand. Das Altern, Leipzig, 1910. 

Manley and Marine. Journ. Am. Med. Ass., lxvii, 260, 1916. 

Marshall. The Physiology of Reproduction, London, 1910. 

Miinzer. Berl. klin. Wchnschr., li, 1914. 

Ott. Internal Secretion from a Physiological and Therapeutic Stand¬ 
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Paton. Regulators of Metabolism, London, 1913. 

Paton, et al. Brit. Med. Journ., i, 189, 232, Jan., 1915. 

Poehl, Tarchanoff, and Wachs. Rational Organotherapy, London, 1906. 
Richet. Presse med., Reprint, 1920. 

Rose. Berl. klin. Wchnschr., li, 1914. 

Sajous. Handb. Med. Treat., ii, 77, Philadelphia, 1919. 

Schafer. The Endocrine Organs, London, 1916. 

-Journ. Neut. Sc., Reprint, 1922. 

Scott. Practitioner, London, xcv, 1915. 

Shaw. Organotherapy, Chicago, 1905. 

Starling. Journ. Am. Med. Ass., 1, 835, 1908. 

Steinach. Verjtingling, Leipzig, 1920. 

Strauss. N. Y. Med. Journ., Reprint, 1921. 

Symposium on the Glands of Internal Secretion, Surg., Gynec. & Obst. v 
xxv, 225, 1917 5 Journ. Am. Med. Ass., lxxix, 89, 1922. 

Vincent. Internal Secretion and the Ductless Glands, London, 1912. 
Waller. Practitioner, London, xciv, 281, 1915. 

Walton. Journ. Exper. Med., xx, 1914. 

Weil. Die innere Sekretion, Berlin, 1922. 

Weiland. Therap. Monatsh., xxviii, 229, 1914. 

Wilson. Canad. Med. Ass. Journ., v, 1915. 

Wishart. Ibid., v, 676, 1915. 

Yoshimata. Quart. Journ. Exper. Physiol., xiii, 5, 1922. 



784 


ORGANOTHERAPEUTICS 


The Thyroid 

Abderhalden. Arch. f. d. ges. Physiol., clxii, 99, 1915. 

Allen. Journ. Exper. Zool., xxiv, 499, 1918. 

Asher and Abelin. Biochem. Ztschr., lxx, 259, 1917. 

Asher and Flack. Ztschr. f. Biol., lv, 7, 1911. 

Barrett. Arch. Neurol. & Psycho-Path., ii, 628, 1919. 

Bartelmez. Anat. Record, ix, 1, 1915. 

Basinger. Arch. Int. Med., xvii, 260, 1916. 

Baumann. Ztschr. f. phys. Chemie, xxi, 319, 1895. 

Bensley. Am. Journ. Anat., xix, 37, 57, 1916. 

Bergmann, von. Ztschr. f. exper. Path. u. Therap., v, 646, 1909. 
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Blum and Griitzner. Ztschr. f. phys. Chemie, xci, 400, 1914. 

Boltin. Monatschr. f. Psychiat. u. Neurol., xxxiii, 119, 1913. 
Boothby. Boston Med. & Surg. Journ., clxxv, 524, 1916. 

Bordley. Journ. Am. Med. Ass., lxvii, 412, 1916. 

Bram. Endocrinology, iii, 467, 1919. 

Burget. Am. Journ. Physiol., xliv, 492, 1917. 

Caldwell. Ibid., xxx, 42, 1912. 

Cameron. Biochem. Journ., vii, 466, 1913. 

-Journ. Biol. Chem., xvi, 465, 1914. 

Cameron and Carmichael. Ibid., xlv., 69, 1920; xlvi, 35, 1921. 
-Am. Journ. Physiol., lviii, 1, 1921. 

Cameron and Vincent. Journ. Med. Research, xxxii, 25, 1915. 
Cannon. Journ. Am. Med. Ass., lxxix, 1922. 

Cannon and Cattell. Am. Journ. Physiol., xli, 39, 58, 74, 1916. 
Carlson. Ibid., xxxiii, 143, 1914. 

Carlson and Woelfel. Ibid., xxvi, 32, 1910. 

Carlson, Rooks, and McKie. Ibid., xxx, 129, 1912. 

Clemens. Arch. Pediat., xxvii, 353, 1910. 

Cramer and Krause. Proc. Roy. Soc., London, B, lxxxvi, 550, 1913. 
Cramer and McCall. Quart. Journ. Exper. Physiol., ii, 97, 1919. 
Crile. Am. Journ. Med. Sc., cxlv, 28, 1913. 

Cunningham. Journ. Exper. Med., iii, 147, 1898. 

Denis and Aub. Arch. Int. Med., xx, 964, 1917. 

DuBois. Ibid., xxv, 163, 915, 1916. 

Edmund. Ophthalmoscope, xiv, 300, 1916. 

Eiselberg, von. Arch. f. klin. Chir., cvi, 1, 1915. 

Eisner. Am. Journ. Med. Sc., cxlvii, 634, 1914. 

Eppinger and Hofer. Mitt. a. d. Grenzgeh. d. Med. u. Chir., xxxi, 
1918. 

Eppinger, Falta and Rudinger. Ztschr. f. klin. Med., lxvi, 1, 1908. 





REFERENCES 


785 


Ewald. Ztschr. f. Krebsforsch., xv, 85, 1915. 

Falta, Newburgh and Noble. Ztschr. f. klin. Med., lxxi, 97, 1911. 
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Forbes and Beegle. The Iodin Content of Foods, Bull. Ohio Agric. 

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Frazier and Peet. Am. Journ. Physiol., xxxv, 486, 1915; xxxviii, 93, 
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French. Ibid., xxx, 56, 1912. 

Gauthier. L’Qpotherapie Thyroidienne, Paris, 1913. 

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Gaylord and Marsh. Carcinoma of the Salmonoid Fishes, Washington, 

1914. 


Geyelin. Arch. Int, Med., xvi, 975, 1915. 

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-Am. Journ. Anat., xv, 431, 1914. 

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Hesselberg. Journ. Exper. Med., xxi, 164, 1915. 

Hewitt. Quart. Journ. Exper. Physiol., viii, 113, 297, 1914. 
Hofstaetter. Mitt. a. d. Grenzgeb. Med. u. Chir., xxxi, 102, 1918. 
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Hoskins. Journ. Exper. Zool., xxi, 295, 1916. . 

Houssay. Rev. d. Instit. Bact., Buenos Aires, ii, 629, 1920. 

Howard. Endocrinology and Metabolism, i, 299, 1922. 

Hunt. Journ. Am. Med. Ass., lvii, 1032, 1911. 

-Am. Journ. Physiol., lxiii, 257, 1923. 

Hunt and Seidell. Bull. 47, Hyg. Lab. U. S. P. H. and M. H. S., 1908. 

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Hunt and Simpson. Journ. Biol. Chem., xx, 119, 1915. 

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Jackson. Am. Journ. Anat., xx, 305, 19 1 6 - . 

Janney. Arch. Int. Med., xxii, 174, 1187, 1918 ; xxvi, 297, 1 • 

_Endocrinology and Metabolism, i, 379, 1922. 

Jones. Journ. Exper. Med., xvii, 547, 1913. 








786 


ORGANOTHERAPEUTICS 


Kendall. Journ. Biol. Chem., xx, 501, 1914; xxxix, 125, 1919. 

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-Nobel Lecture, 1910. 

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Launoy. Thyroides, Parathyroides, Thymus, Paris, 1914. 

Lenhart. Journ. Exper. Med., xxii, 739, 1915. 

Leopold-Levi and de Rothschild. Nouvelles Etudes Physio-pathologie du 
Corps Thyroides, Paris, 1911. 

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-Am. Journ. Physiol., lvi, 168, 1921. 







788 


ORGANOTHERAPEUTICS 


Vincent. Endocrinology and Metabolism, i, 223, 1922. 

Watts. Am. Journ. Physiol., xxxviii, 356, 1915. 

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The Parathyroids 

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Carlson and Jacobson. Ibid., xxv, 403, 1910; xxviii, 133, 1911. 
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Erdheim and Stumme. Beitr. z. path. Anat., xlvi, 1909. 

Falta. The Ductless Glandular Diseases, translated by Meyers, Phila¬ 
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Eenger. Journ. Biol. Chem., xxi, 283, 1915; xxv, 417, 1916. 

Franchini. Berl. klin. Wchnschr., xlvii, 613, 670, 719, 1910. 

Frank. Journ. Am. Med. Ass., lxxiii, 1764, 1919. 

Frankl-Hochwart and Frohlich. Arch. f. exper. Path. u. Pharmakol., 
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Frohlich. Wien. klin. Rundschau, xv, 883, 1901. 

Fry. Quart. Journ. Med., viii, 277, 1915. 

Gaines. Am. Journ. Physiol., xxxviii, 285, 1915. 

Gemelli. Arch, per le sc. med., xxx, 341, 1906. 

Gibson and Martin. Arch. Int. Med., xxvii, 351, 1921. 

Goetsch, E. Quart- Journ. Med., vii, 173, 1914. 

-Johns Hopkins Hosp. Bull., xxviii, 29, 1916. 







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Goetsch, E. Surg., Gynec. & Obst., xxv, 229, 1917. 

Goetsch, Cushing and Jacobson. Johns Hopkins Hosp. Bull., xxii, 165, 
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Hammet, Patten and Switser. Am. Journ. Physiol., li, 588, 1920. 
Hammond. Quart. Journ. Physiol., vi, 311, 1913. 

Hanke and Koessler. Journ. Biol. Chem., lxiii, 587, 1920. 

Harrison. Journ. Am. Med. Ass., lxiii, 1977, 1915. 

Harvey. Biochem. Journ., iv, 431, 1909. 

Hatai. Am. Journ. Anat., xv, 118, 1913. 

Heaney. Surg., Gynec. & Obst., xvii, 103, 1913. 

Herring. Quart. Journ. Exper. Physiol., viii, 254, 1914. 

Hewlett. Arch. Int. Med., ix, 32, 1912. 

Hill and Simpson. Am. Journ. Physiol., xxxv, 361, 1914. 

Hofstatter. Zentralbl. f. Gynak., xliv, 68, 1920. 

Hoppe-Seyler. Miinchen. med. Wchnschr., lxii, 1633, 1915. 

Hoskins. Journ. Am. Med. Ass., lxvi, 733, 1916. 

Hoskins and Hoskins. Endocrinology, iv, 1, 1920. 

Hoskins and McPeek. Am. Journ. Physiol., xxxii, 241, 1913. 

Hoskins and Means. Journ. Pharmacol. & Exper. Therap., iv, 435, 
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Houghton and Merril. Journ. Am. Med. Ass., li, 1849, 1908. 

Houssay. Endocrinology, ii, 94, 1918. 

Howard. Am. Journ. Med. Sc., clviii, 830, 1918. 

Howell. Journ. Exper. Med., iii, 245, 1898. 

Jackson. Am. Journ. Anat., xxi, 321, 1917. 

Jackson and Mills. Journ. Lab. & Clin. Med., v, 9, 1919. 

Kay. Endocrinology, v, 325, 1921. 

Keeton and Becht. Am. Journ. Physiol., xlix, 218, 1919. 

King and Stoland. Ibid., xxxii, 405, 1914. 

Kojima. Quart. Journ. Exper. Physiol., xi, 319, 1917. 

Krogh. Anatomy and Physiology of the Capillaries, New Haven, 1922. 
Kross. Am. Journ. Obst. & Gynec., iv, 19, 1922. 

Larson. Am. Journ. Physiol., xlix, 55, 1919. 

Lewis. Johns Hopkins Hosp. Bull., xvi, 156, 1905. 

-Journ. Am. Med. Ass., Iv, 1002, 1910. 

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Lewis and Miller. Arch. Int. Med., xii, 137, 1913. 

Lewis, Miller and Matthews. Ibid., vii, 785, 1911. 

Lisser. Endocrinology., vi, 15, 1922. 

Ludhum and Carron-White. Journ. Am. Med. Ass., lxiv, 937, 1915. 
Mann. Am. Journ. Physiol., xli, 173, 1916. 

Maranon. Endocrinology, v, 159, 1921. 

Marinus. Am. Journ. Physiol., xlix, 238, 1919. 

Maxwell. Univ. Calif. Pub. Physiol., v, 5, 1916. 




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Herrmann. Monatschr. f. Geburtsh. u. Gynaek., lxi, 1, 1915. 
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Kellogg. Journ. Exper. Zobl., i, 594, 1904. 

Klein. Monatschr. f. Geburtsh. u. Gynaek., xxxvii, 169, 1913. 
Kohler. Centralbl. f. Gynak., xxxix, 651, 1915; xliii, 358, 1919. 
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Osborne. Journ. Am. Med. Ass., liv, 670, 1910. 

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Schiffmann and Yystavel. Wien. klin. Wchnschr., xxvi, 26, 1913. 

The Testes 

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Husy and Wallert. Ztschr. f. Geburtsh. u. Gynak., lxxvii, 177> 1915. 
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Lillie. Journ. Exper. Zool., xxxiii, 371, 1917. 

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Lydston. Journ. Am. Med. Ass., lxvi, 1540, 1916; lxx, 907, 1918; lxxii, 
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Massaglia. Endocrinology, iv, 547, 1920. 

Meyers. Anat. Record, x, 228, 1916. 

Moore. Journ. Exper. Zool., xxviii, 137, 409, 1919; xxxiii, 129, 1921. 

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Morgan. Endocrinology, iv, 381, 1920. 

Murlin and Bailey. Surg., Gynec. & Obst., xxv, 372, 1917. 

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Whitehead. Am. Journ. Anat., vi, 63, 1912. 

Zoth. Arch. f. d. ges. Physiol., lxii, 335, 1896; lxix, 382, 1898. 

The Prostate Gland 

Kondaleon. Wien. klin. Wchnschr., xlvi, 1098, 1920. 

Macht. Journ. d’urol. med. et chir., iv, 255, 1920. 

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Cowdrv, McCord, Jelliffe and Horrax. Endocrinology and Metabolism, 
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-Surg., Gynec. & Obst., xxv, 250, 1917. 






804 


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Zandren. Acta Med. Scand., liv, 323, 1921. 


The Thymus 

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Basch. Jahrb. f. Kinderh., lxviii, 645, 1908. 

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Bergstrand. Endocrinology, vi, 477, 1922. 

Bircher. Berl. klin. Wchnschr., xlviii, 819, 1911. 

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Eddy. Canad. Med. Journ., ix, 203, 1919. 

-Endocrinology, v, 461, 1921. 

Friedlander. Arch. Pediat., xxviii, 810, 1911. 

Gudernatsch. Am. Journ. Anat., xv, 431, 1914. 

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Hammar. Beitr. z. klin. Chir., civ, 469, 1917. 

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Hoskins, R. G. Endocrinology and Metabolism, ii, 371, 1922. 

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80G 


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Wolfert. Ibid., xix, 105, 1917. 

The Gastric and Duodenal Mucosa 

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Beveridge. Am. Med., xx, 255, 1914. 

Carlson. Physiol. Revs., iii, 1, 1923. 

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Draper. Journ. Am. Med. Ass., lvii, 1338, 1911. 

Edkins. Journ. Physiol., xxxiv, 133, 1906. 

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Ewald. Therap. d. Gegenw., lvi, 5, 1915. 

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Hedon. Compt. rend. Soc. de biol., lxxiv, 375, 1913. 

Henriquez and Hallion. Ibid., lvi, 322, 1904; lxi, 488, 1911. 

Hesse. Therap. Monatsh., xxvii, 1913. 

Koch. Endocrinology and Metabolism, ii, 735, 1922. 

Koch, Luckhardt and Keeton. Am. Journ. Physiol, Iii, 508, 1920. 
Kuhlwein. Arch. f. d. ges. Physiol., cxci, 99, 1921. 

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Loeb and Stadler. Arch. f. exper. Path. u. Pharmakol., lxxvi, 326, 1914. 
Luckhardt, Henn and Palmer. Am. Journ. Physiol., lix, 487, 1922. 
Magnus. Naturwissenschaften, Reprint, 1920. 

Minkowski. Arch. f. exper. Path. u. Pharmakol., lxiii, 271, 1908. 

Moore, Edie and Abram. Biochem. Journ., i, 28, 1906: iii, 82, 1908. 
Pemberton and Sweet. Arch. Int. Med., ii, 204, 1908; vi, 466, 1910. 
Sabatowski. Wien. klin. Wchnschr., xxv, 116, 1912. 

Schlaginweit. Arch, internat. de pharmacol., xxiii, 77, 1913. 

Schwartz and Lederer. Arch. f. d. ges. Physiol., cxxiv, 553, 1908. 
Starling. Proc. Roy. Soc. Med., viii, 9, 1914. 

Whipple, Cooke and Stearns. Journ. Exper. Med., xxv, 479, 1917. 
Whipple, Stone and Bernheim. Ibid., xvii, 286, 307, 1913; xix, 144, 
1914. 

Wieland. Arch. f. ges. Physiol., cxlvii, 171, 1912. 

Zuelzer, Dohm and Marxer. Berl. klin. Wchnschr., xlv, 2065, 1908. 
-Med. Klin., vi, 535, 1910. 



REFERENCES 


807 


The Blood 

Alexander. Brit. Med. Journ., i, 355, 1911. 

Archibald and Moore. Arch. Int. Med., xiv, 120, 1914. 

Floyd and Lucas. Journ. Med. Research, xx, 466, 1909. 

Hektoen and Carlson. Journ. Infect. Dis., vii, 319, 1910. 

Hiss. Journ. Med. Research, xix, 373, 1908. 

Hiss and Dwyer. N. Y. Med. Rec., Ixxxiv, 1913. 

Hiss and Zinsser. Journ. Med. Research, xix, 399, 1908; xx, 245, 1909. 
Lambert. Am. Journ. Med. Sc., 1909. 

Mairet and Vires. Arch. f. Physiol., ix, 353. 

Marfori. Arch. ital. de biol., lxviii, 113, 1918. 

Todd and White. Proc. Roy. Soc. London, Ixxxiv, 452, 1911. 

Vincent. Endocrinology, ii, 420, 1918. 

Williams and Youland. Journ. Med. Research, xxxi, 1915. 

Youland. Ibid., xxxi, 1915. 

Zinsser, McCoy and Chapin. Ibid., xxiv, 483, 1911. 





. 



INDEX 

NOTE: Therapeutic agents appear in black-face type, as Balneology. 

Subjects other than treatment appear in plain capitals, as Acromegaly. 
All headings are alphabetized) and the relation of the sub-headings shown 
by indentation. 


Abdominal conditions, radium therapy in, 

576 

Abscess, apical, 498 
—• — physiotherapy in, 498 

— Thermotherapy in. Bee Thermotherapy. 
Absorption, colloidal theory of, 52 

— in intestinal tract, 51 

— of dissolved substances, 55 
-general application, 55 

-predilection for certain organs, 55 

-“selective” theory, 51 

Absorptive system, 49 

— example of, 51, 52 

— phases of, 49-51 

Acids, action on protein colloids, 33, 34 

— specific differences of, 30 
-causes of, 30 

Acne, physiotherapy in, 513 

— thermotherapy in. Bee Thermotherapy. 

— x-ray therapy in, 615, 616 

Acne keloid, x-ray therapy in, 613 
Acromegaly. Bee Organotherapeutics, 733, 
734 

Actinic rays. See Ultraviolet rays. 
Actinomycosis, x-ray therapy in, 612 
Addison’s disease, organotherapeutics in, 
714, 715, 720 

Adenitis, physiotherapy in, 526 

— tuberculous, 628 

-x-ray therapy in, 628, 629 

Adrenal cortex, 712 

Adrenal function, theories of, 704-706 

Adrenalin. See Epinephrin. 

Adrenals, in organotherapeutics, 701-707 
Adsorbents, examples of, 26 
Adsorption, example of, 26 

— inequalities of, 26-28 

— laws of, 54 

Alimentary disorders, balneology in. See 
Balneology. 

Alopecia, physiotherapy in, 512 
Alopecia areata, physiotherapy in, 513 
Amenorrhea, physiotherapy in, 519 

— thermotherapy in. See Thermotherapy. 
Amperage, in x-ray therapy, 586, 587 
Anal fissure, physiotherapy in, 501 
Anemia, climatic treatment of, 204 

— hydrotherapy in, 429 

— physiotherapy in, 492 
Angiomata, physiotherapy in, 513--. 

— radium in, 570-572 

Antidotes, in poisoning, 162, 164, 166 


Apical abscess. See Abscess. 
Appendicitis, catarrhal, thermotherapy 
in. Bee Thermotherapy. 

— physiotherapy in, 498 
Arteriosclerosis, hydrotherapy in, 426 

— physiotherapy in, 490, 491 
Arthritis, chronic, 556 
-radium therapy in, 556 

— gonorrheal, 557 

- hydrotherapy in, 451 

-radium therapy in, 557 

-thermotherapy in. Bee Thermo¬ 
therapy. 

— physiotherapy in, 487-489 
Arthritis deformans, physiotherapy in, 

488 

— radium therapy in, 556 

Artificial feeding. Bee Nutrition and 
Dietetics. 

Aspermia, due to effect of x-rays, 593, 594 
Asthma, bronchial, climatic treatment 
of, 205 

— hydrotherapy in, 427 

— x-rays in, 630 

Aural diseases. Bee Ear, diseases of. 

Balneology, Aix-la-Chapelle water, 453 

— alimentary disorders and, 468 

— anemia and, 466 

— bladder diseases and, 467, 468 

— blood diseases and, 466 

— cardiac diseases and, 467 

— definition of, 453 

— effects of regime in, 454 

— Kreuznach water, 453 

— medical personnel at spas, 454, 455 
—• mineral waters, 459 

-action of, 459, 461 

-alkalies, 460 

-arsenicals, 461 

-earthy, 461 

-iron, 461 

-salines, 460 

-sulphide, 461 

—•— chemical analyses of, 455, 456 

-classification of, 457 

-alkaline waters, 458 

-location of springs, 458 

-arsenical waters, 459 

-location of springs, 459 

-bitter waters, 458 

-location of springs, 458 

809 



810 


INDEX 


Balneology, mineral waters, classification 
of, calcareous group, 459 

-location of springs, 459 

-common salt waters, 457, 458 

-location of springs, 457, 458 

-iron waters, 458 

-location of springs, 458, 459 

-simple thermal waters, 457 

-location of springs, 457 

-sulphur waters, 459 

-location of springs, 459 

-constituents of, 453-457 

-curative properties of, 453 

-radio-activity in, 456, 457 

— psychic influence in, 454 

— references, 469, 470 

— renal diseases and, 467, 468 

— respiratory diseases and, 466 
-asthma, 466 

-bronchitis, 466 

-emphysema, 466 

-tuberculosis, 466 

— rheumatism and, 468 

— spa, 453 

-chemical analyses of waters, 455, 456 

-in America, 455, 456 

-in Europe, 455, 456 

-choice of, 461-465 

-climate of, 465 

-effects of regime, 454 

-facilities for physicotherapy, 465 

-in tardy convalescence, 462, 465 

-selection of, 466 

-medical personnel of, 454, 455 

-temperature of, 456 

-various uses of, 461 

— spas, 453 

-American, 463, 464 

--European, 463, 464 

— spas and springs, 457 

-location, in various countries, 457-459 

— spa treatment, 463 
-adjuvants in, 463 

-cardiovascular diseases and, 462, 463 

-chronic diseases and, 462 

-metabolic disorders and, 462 

-syphilis and, 463 

— springs, 453 

-in United States, 454 

— --temperature of, 456 

-radio-activity in, 454 

— Vichy water, 453 

— See also Hydrotherapy. 

Balneotherapy. See Balneology. 

Banti’s disease, x-ray therapy 'in, 628, 629 
Basedow’s disease. See Goiter, toxic. 
Baths. See Hydrotherapy. 

Beverages. See Nutrition and Dietetics. 
Bier’s hyperemia. See Thermotherapy. 
Bladder, diseases of, balneology in. See 

Balneology. 

— ulcer of, fulguration in, 577 
Blastomycosis, x-ray therapy in, 612 
Blood, alkali reserve of, 83 

— as liquid colloid, 53 

— chlorids in, 53 


Blood, composition of, 53 

— diseases of, balneology in. See Balneol¬ 
ogy. 

— dissolved substances in, 53 

-distribution of, 53 

-factors influencing, 53, 54 

— effect of altitude, 194-196 

— effect of barometric pressure, 194, 195 

— effect of x-ray therapy, 590, 591 

— in organotherapy. See Organotherapeu- 
tics. 

— in parathyroid tetany, 678, 679 

— sulphates in, 53 

— urea in, 53 

Blood transfusion in, experimental dia¬ 
betes, 691, 692 

— hemorrhage, 48 

— shock, 48 

Blood-vessels, diseases of, physiotherapy 
in, 490-492 

Body fluids, colloidal constituents in, 38 

-effects of, 38 

Boils, physiotherapy in, 514 

— thermotherapv in. See Thermotherapy. 
Bones, diseases of, physiotherapy in. See 

Physiotherapy. 

— tuberculosis of, physiotherapy in, 487 
Brand bath in, pneumonia. See Hydro¬ 
therapy. 

— typhoid fever. See Hydrotherapy. 
Breast, diseases of, radium therapy in, 

575, 576 

Bright’s disease. See Nephritis. 
Bromidrosis, x-ray therapy in, 617, 618 
Bronchial asthma. See Asthma. 
Bronchitis, acute, 42S 
-hydrotherapy in, 428 

— climatic treatment of, 205 

— physiotherapy in, 504 

— thermotherapy in. See Thermotherapy. 
Bronchopneumonia, physiotherapy in, 

504 

Bruises, thermotherapy in. See Thermo¬ 
therapy. 

Burns, thermotherapy in. See Thermo¬ 
therapy. 

— x-ray, 514 

-physiotherapy in, 514 

Caffein derivatives, “diuretic” action of, 
43 

Callosities, physiotherapy in, 515, 516 
Calory. See Nutrition and Dietetics. 
Cancer, epithelial, physiotherapy in, 516 

Carbohydrate requirement. See Nutri¬ 
tion and Dietetics. 

Carbohydrates. See Nutrition and Die¬ 
tetics. 

Carbuncle, physiotherapy in, 514 
Carcinoma, x-ray therapy in, 618-621 
Carcinomata, epidermoid, radium therapy 
in, 569 

Cardiac diseases, balneology in. See Bal¬ 
neology. 

Cardiac disturbances, functional, phys¬ 
iotherapy in, 495-497 




INDEX 


Cardiac lesions, organic valvular, 
physiotherapy in, 403 
Cardiovascular diseases, physiotherapy 
in. See Physiotherapy. 

Carrel-Dakin treatment of empyema, 511 
Cataphoresis. See Ionization. 

Catarrhal conditions, climatic treatment 
of, 205 

Catarrhal deafness. See Deafness. 
Cathartics, saline, action of, 47, 48 
Cell, absorptive power of, 26 

— biological theories concerning, 20 

— chemical constituents of, 5, 6 

— entry of dissolved substance into, 55 
-factors influencing, 55 

-mechanism of, 55 

-rate of, 55 

— lipoids in, 23 

— osmotic, 57 

— physiochemical constitution of, 5 

— secreting, 44 
-examples of, 44 

— solvent powers of, 23, 24, 25 
Cellular membranes. See Membrane. 
Cerebral degeneration. See Degeneration. 
Cervical erosions. See Erosions. 

Charts, for muscle nerve testing, 470, 480 
Chlorosis, hydrotherapy in, 420 

— physiotherapy in, 402 
Cholecystitis, physiotherapy in, 408 

— thermotherapy in. See Thermotherapy. 
Cholera infantum, hydrotherapy in, 441 
Chorea, hydrotherapy in, 445 
Cicatrices. See Scars 

Circulatory diseases, hydrotherapy in. 

See Hydrotherapy. 

Climate. See Climatology, 168 
Climatology, climate, 168 

-definition of, 168 

-effects on, 168 

-animal life, 168 

-plant life, 168 

— — factors modifying, 170-182 

-man’s relation to, 168, 160, 170 

-physiological effects on man, 170 

-psychology of, 200, 201 

— climatotlierapy, 204 
-anemia and, 204 

-bronchial asthma and, 205 

-bronchitis and, 205 

--catarrhal conditions and, 205 

-digestive disorders and, 206 

-gout and, 204 

-heart diseases and, 205, 206 

-kidney disorders and, 206 

-nervous disorders and, 206, 207 

-respiratory affections and, 205 

-skin diseases and, 206 

-tuberculosis and, 201-204 

-tuberculous laryngitis and, 205 

— medical, 168 

-principles of, 168-170 

- See also Climatotherapy. 

— meteorological, 170 

-physical elements in, 170 

-altitude, 178, 170 


811 

Climatology, meteorological, physical ele¬ 
ments in, atmosphere, 180 

-composition of, 180, 181 

-uniformity of, 180 

—*-dust and impurities in, 181 

-atmospheric humidity, 173 

-absolute, 174 

-aqueous vapors, 174 

-determination of, 174 

-rain, 175, 176 

-relative, 174 

-barometric pressure, 181 

-electricity, 180 

-soil, 170, 180 

-temperature, 170, 171 

-vegetation, influence on climate, 

182 

-winds, 176 

-anticyclones, 177, 178 

--cyclones, 177, 178 

-trade winds, 177 

— physiologic adaptation, 160 

— physiological, 160 

-definition of, 160 

-principles of, 160 

— physiological and medical, 183 
-air, 183 

-— alveolar, 102 

-composition of, 102 

-chemical pollution of, 101 

-motion of, 180 

-physiological influence of, 189, 

190 

-rebreathing of, 188 

-effects of, 188-100 

-temperature of, 180 

--effects on body, 180-101, 107 

-air pressure, 192 

-in relation to disease, 102 

-atmospheric humidity, 187 

-physiological influence of, 187-191 

-barometric pressure, 191 

--at sea-level, 191 

-effect on blood, 104 

-physiological influence of, 101-106 

-blood changes, 195 

-in high altitudes, 195, 106 

-in low altitudes, 106 

-body temperature, 185 

-regulation by, 188 

-humidity, 190, 101 

-perspiration, 188 

-temperature, 190, 191 

-variations of, 185 

-dust and atmospheric impurities, 198 

-pathological conditions due to, 

190, 200 

-external temperature, 184 

-anesthetized mammals and, 186 

-body temperature and, 185 

-metabolism and, 184 

-physiological reaction to, 183, 184, 

186 

-heliotherapy, 196, 197 

-high altitudes, 193 

-effect on blood, 104, 195 




812 


INDEX 


Climatology, physiological and chemical, 
high altitudes, metabolic disturbances 
in, 193, 194 

-mountain sickness in, 193 

-cause of, 194 

-symptoms of, 194 

-physiological influences of, 193 

-—cause of, 193 

-insolation, 194 

-light, 190 

-effect in tropics, 196 

-physiological influence of, 196 

-psychic influence of, 196 

-physical environment, 198 

-individual reaction to, 198 

-physiological functions, 198 

-'modification by high altitudes, 198 

-physiological therapeutics, 185 

-climate as a factor in, 185 

-respiratory exchange, 193 

-regulation of, 193 

-ventilation, 188-191 

-effects on body, 190 

— references, 207-210 
Climatotherapy. See Climatology. 
Coefficient, isotonic. See Coefficient. 
Coefficient of partition, 23 

Cold. See Hydrotherapy. 

Colloid material, liquid, 35-37 

— examples of, 35 

-blood, 35 

-lymph, 35 

Colloidal state, effect of external con¬ 
ditions on, 32 

Colloids, classification of, 32 

-emulsion, 32 

-constituents of, 32 

-suspension, 32 

— colloidal and crystalloidal state, 7 
-definition of, 7 

— conversion into crystalloids, 50 

— discovery of, 6 

— effect on crystalloids, 38 

— in blood, 35, 36 

— in lymph, 36 

— in various substances, 6, 7 

— molecular weight of, 6 

— osmotic pressure in, 6 

— protein, 33 

-action of acids on, 33, 34 

-action of electrolytes on, 37 

-example of, 37 

-action of salts on, 47 

-effect of non-electrolytes on, 34 

— proteins in, 33 

-water absorption by, 33 

— tissue, 41 

-action of electrolytes on, 41, 42 

— types of, 7, S 

Condiments. See Nutrition and Dietetics. 
Conjunctivitis, thermotherapy in. See 
Thermotherapy. 

Constipation, cathartics in, 4S 

-action of, 48 

-— chronic, 499 
-physiotherapy in, 499 


Constipation, colloids in, 48 
-action of, 48 

Constitutional disorders, hydrotherapy 
in, 429 

Contractures, radium therapy in, 570 
Cornet method, in pulmonary tubercu¬ 
losis. See Hydrotherapy, 440, 441 
Corns, treatment of, 515, 516 
Corpus luteum, in organotherapeutics, 
750, 751 

Coryza, physiotherapy in, 501 
—thermotherapy in. See Thermotherapy. 
Cretinism, organotherapeutics in, 659-662 
Cross-fire in radium therapy, 564, 566 
Crystalloids, classification of, 9 

- electrolytes, 9 

-non-electrolytes, 9 

— diffusion of, 6, 7 

— in various substances, 6 

— molecular weight of, 6 

— osmotic pressure in, 6 

— solutions of, 6 

Curie therapy. See Radium therapy. 

Cutaneous diseases, physiotherapy in, 
512 

D. A. H., or effort syndrome, 495 
d’Arsonval current. See Electrotherapy; 
Thermotherapy. 

Deafness, catarrhal, physiotherapy in, 
527 

Degeneration, cerebral, 472 
-physiotherapy in, 472 

— reaction of, 295 

Dermatitis papillaris capillitii, x-ray 
therapy in, 613 

Dermatology, x-rays in. See Skin diseases. 
Detoxication, principle of, 56 
Diabetes insipidus, hvdrotherapy in, 
429 

Diabetes mellitus, hvdrotherapy in, 
429 

— organotherapeutics in, 701, 773, 774 
Diabetes, pancreatic. See Organothera¬ 
peutics, 685-692 

Diathermic cauterization. See Electro¬ 
therapy. 

Diathermia. See Diathermy. 

Diathermy. See Electrotherapy; Thermo¬ 
therapy. 

Diet. See Nutrition and Dietetics. 

Dietary standards. See Nutrition and 

Dietetics. 

Dietetics. See Nutrition and Dietetics. 
Diffusion, colloids in, 21 

— crystalloids in, 21 

— definition of, 20 

— factors in, 21 

— rate of, 21 
Digestion, 108, 109 

Digestive disorders, climatic treatment of, 
206 

— in parathyroid tetany, 676, 677 
Digitalis, “diuretic” action of, 43 
Diphtheria carriers, treatment of by 

ultraviolet light. See Physiotherapy. 



INDEX 


813 


Dissociation of substances, 10 

— degrees of, 10 
-examples of, 10 

— effects of, 10 
Distribution coefficient, 23 
Diuretics, saline, action of, 47 
Donnan’s equilibrium equation, 9 
Douches. See Hydrotherapy. 

Ductless glands, physiotherapy in, 526 
Duodenal ulcer. See Ulcer. 

Dust inhalation, as etiologic factor in 
disease, 199, 200 

Dysmenorrhea, physiotherapy in, 520 

— thermotherapy in. See Thermotherapy. 
Dystrophy, organotherapy in, 638 

Ear, diseases of, physiotherapy in. See 
Physiotherapy. 

— radium therapy in, 573, 574 
Eczema, physiotherapy in, 516 

— x-ray therapy in, 607, 608 
Edema, production of, 40 
-mechanism of, 40 

Effort syndrome, or D. A. H., 495 
Egg-albumin water, 138 
Electrical terms. See Electrotherapy. 
Electrolytes, 9, 59 

— action in body, 9 

— action on colloid tissue, 41, 42 

— chemistry of, 30 

— dissociation of, 30 

-ions in, 30, 31 

-theory of, 29 

-importance of, 29 

Electrotherapy, apparatus, 319 

— bipolar current, 305 

— circulatory stasis and. 299 

— combined currents, 303 

-galvanism and faradism, 303 

-apparatus for, 303 

— condenser electrodes, 316, 317 
-types of, 317 

— d’Arsonval current, 304 

— diathermic cauterization, 315 

— diathermy, 304 

-apparatus, 309 

-care of, 310 

-portable, 310 

-autocondensation, 313, 314 

-contra-indications, 314 

-precautions in, 314 

-bipolar current in, 305 

-current employed in, 305 

-d’Arsonval current in, 304 

-definition of, 304 

-development of, 304 

-electrodes, 310 

-types of, 310 

-experimental work in, 307-309 

-general effects of, 307 

-general technic of, 310 

-inspection of apparatus, 311 

-milliamperes used, 311 

-- — preparation of patient, 310 

-precautions necessary, 311, 312 

-history of, 304 , 


Electrotherapy, diathermy, local effects 
of, 307 

-milliamperes necessary for, 309 

-physics of, 305 

—' — physiological effects of, 307 

-special technic in, 312 

-brain, 312 

-extremities, 313 

-heart, 312 

-lungs, 312 

-spine, 312 

-surgical, 314 

— -advantages of, 315 

-definition of, 314, 315 

-disadvantages of, 315 

-effect on tissue, 316 

-milliamperes in, 316 

-synonym, 315 

-technic of, 315, 316 

-value of, 316 

-synonyms, 304 

— electrical terms, 282, 283 
-ampere, 282 

-Ohm, 282 

-Ohm’s law, 282 

-volt, 282 

—electrodes, 316, 317 

-types of, 316 

-condenser, 316, 317 

-vacuum, 316, 317 

— faradic current, 299 

-action on muscle, 301, 302 

-apparatus for, 301 

-history of, 299 

--in obesity, 302, 303 

-effects of, 303 

-- physics of, 299, 300 

-physiological effects of, 300 

— galvanic bath, 289 
-general, 290 

— galvanic cell, 282 

— galvanic current, 281 

-apparatus, 281 

-batteries, 282 

-electrodes, 286 

----construction of, 286, 287 

-selection of, 286 

-general treatment and, 290 

-interrupted, 294 

-physiological effects of, 295 

-reaction of degeneration, 295 

-reaction, of normal muscle to, 295 

-sources of, 294 

-local treatment and, 289 

-physics of, 281 

-physiological effects of, 283, 296 

-polarity tests, 284 

-precautions in use of, 288 

—* — preparation of patient, 287 

-Sclinee bath, 289 

-sources of, 281 

-technic of use, 286 

-therapeutic uses of, 284-290 

-wave, 294 

-apparatus for, 295, 296 

-sources of, 295 





814 


INDEX 


Electrotherapy, high frequency current, 304 

-apparatus, 305, 300 

-spark-gap, care of, 306 

-standard d’Arsonval machine, 305 

-bipolar d’Arsonval, 305 

-dangers of small machines, 319 

-effects of, 305 

-milliamperemeter, 306, 307 

-types of, 304, 316 

-d’Arsonval, 304 

-Oudin, 304, 316 

-Tesla, 304, 316 

-unipolar, 316 

-condenser electrodes, 316, 317 

-types of, 317 

-physiological effects of, 317, 318 

-systemic effect of, 318 

-technic of application, 318, 319 

-vacuum electrodes, 316, 317 

-types of, 317 

- See also Diathermy. 

— ionization, 290 

-advantages of, 293 

-anions, 291 

-definition of, 291 

-cations, 291 

-definition of, 291 

-chemistry of, 291, 292 

-definition of, 290 

--disadvantages of, 293 

-history of, 290 

-ions, 291 

--definition of, 291 

-polar effects, 291 

-surgical, 293, 294 

-* — removal superfluous hair and, 294 

-technic of, 293, 294 

-uses of, 293, 294 

-technic of, 292, 293 

-typical treatments by, 293 

— Leyden jars, 304, 323, 325 

— neuritis and, 293 

— Oudin current, 304, 316 

— Schnee bath, 289 

— sinusoidal current, 296 

-as substitute for voluntary exercise, 

299 

-definition of, 296 

-in circulatory stasis, 299 

-physics in, 296 

— — physiological effects of, 297 

-technic of application, 298, 299 

-types of, 297 

-interrupted, 297 

-slow, 297 

— static electricity, 319 

-amperage in, 321 

-apparatus, 320 

-care of, 320, 321 

-location of, 320 

-types of, 320 

-charging, 321 

-definition of, 319 

-history of, 319 

-Leyden jars, 323, 325 

-modalities, 322 


Electrotherapy, static electricity, modali¬ 
ties, effects of, on blood-pressure, 322 

-physiological effects, 321, 322 

-tissue contraction, 321 

-polarity, 321 

-tests for, 321 

-preparation of patient, 322 

-types of currents, 322 

-effluve, 325 

-technic of, 325 

-treatment with, 325 

-induced current, ,325 

-Leyden jars, 325 

-method of application, 325, 326 

-Morton wave, 323 

-local effect of, 323 

-physiological effect of, 323 

-technic of treatment, 323 

-value, 323 

-simple charge, 326 

-apparatus, 326 

-effects, 326 

-sparks, 323 

---direct, 324 

-indirect, 324 

-intensity of, 324 

-technic of treatment, 324 

-uses of, 319 

-voltage in, 321, 322 

— See also Physiotherapy. 

— Tesla current, 304, 316 
Empyema, physiotherapy in, 511 


Endarteritis obliterans, physiotherapy 
in, 492 

— thermotherapy in. See Thermotherapy. 
Endocarditis, hydrotherapy in, 426, 427 
Endocrine hypofunction, organotherapv 

in, 643, 644 

Endocrine therapy, 643, 644 
Endocrines. See Ductless glands. 
Endometritis, ionization in, 520, 521 
Endothermy. See Thermotherapy. 
Enuresis, physiotherapy in, 523 
Epinephrin. See Suprarenals, 703-712 
Epithelioma, physiotherapy in, 516 

— prickle-cell, 614. 615 

-x-ray therapy in, 614, 615 

— radium therapy in, 569 

— squamous cell, 614, 615 

-x-ray therapy in, 614, 615 

-x-ray and radium in, 516 

Equilibrium, chemical, 19 
-example of, 19, 20 

— in blood, 16-18 

— principles of, 14, 15 

Ergotherapy. See Occupational therapy. 
Erosions, cervical, physiotherapy in, 
521 


Erythemomelalgia, thermotherapy in. 

See Thermotherapy. 

Erysipelas, physiotherapy in, 516 
— thermotherapy in. See Thermotherapy 
Esophagus, carcinoma of, radium ther¬ 
apy in, 575 

Exercise. See Mechanotherapy; Physio¬ 
therapy, 529-532 




INDEX 


815 


Exophthalmic goiter. See Goiter. 

Eyes, effect of x-ray therapy on, 591 

Faradism. See Faradic current, 299 
Fat requirement. See Nutrition and Die¬ 
tetics. 

Fats. See Nutrition and Dietetics. 

Favus. See Fungus infection. 

Felons, thermotherapy in. See Thermo¬ 
therapy. 

Fibroids, uterine, x-ray therapy in, 594, 
621, 622 

Fibromata of breast, x-ray therapy in, 
622 

Filter, in x-ray therapy, 587 
Finsen light. See Phototherapy; Thermo¬ 
therapy. 

Food. See Nutrition and Dietetics. 
Foods. See Nutrition and Dietetics. 
Foodstuffs. See Nutrition and Dietetics. 
Foot disabilities, physiotherapy in. See 
Physiotherapy. 

Fractures, physiotherapy in, 485, 48 

— See Thermotherapy. 

Fulguration. See Surgical diathermy, 
314-316 

Functional reeducation. See Occupa¬ 
tional therapy. 

Fungus infections, thermotherapy in. 
See Thermotherapy. 

— x-ray therapy in, 612 
Furunculosis, physiotherapy in, 514 

Gall-bladder, diseases of, physiotherapy 
in, 498 

Gall-stones, hydrotherapy in, 435 
Galvanic current. See Electrotherapy. 
Gangrene, thermotherapy in. See Thermo¬ 
therapy. 

Gastric ulcer. See Ulcer. 

Gastritis, physiotherapy in, 498 
Gastro-intestinal diseases, hydrotherapy 
in. See Hydrotherapy. 

— physiotherapy in. See Physiotherapy. 

— x-ray therapy in, 592 
General therapy, 3 

— empirical, 3, 4 

— rational, 3, 4 

— references, 61-68 

— scientific, 4 

Genito-urinary diseases, hydrotherapy in. 
See Hydrotherapy. 

— physiotherapy in. See Physiotherapy. 
Gigantism. See Organotherapeutics, 734 
Glands, diseases of, physiotherapy in, 

524-526 

Glandula pituitaria. See Hypophysis. 
Gluten flour. See Nutrition and Dietetics. 
Goiter, cystic, 524 
-physiotherapy in, 524 

— exophthalmic, 430 

-hydrotherapy in, 430 

-organotherapy in, 656-659 

-physiotherapy in, 526 

-x-ray therapy in, 625, 626 

— toxic. See Exophthalmic. 


Gonorrhea, physiotherapy in, 523 
Gout, climatic treatment of, 204 

— hydrotherapy in, 431 

— physiotherapy in, 489 

— radium therapy in, 557, 558 
Granuloma, x-ray therapy in, 626, 627 
Graves’ disease. See Goiter, exophthalmic. 
Green sickness. See Chlorosis. 
Gymnastics. See Mechanotherapy; Phys¬ 
iotherapy. 

Hay fever, x-ray therapy in, 630. 

Heart, diseases of, climatic treatment of, 
205 

— physiotherapy in, 490, 493-498 

— See also Cardiac diseases. 

Heat. See Hydrotherapy; Thermotherapy. 
Heat therapy. See Thermotherapy. 
Heliotherapy. See Climatology; Photo¬ 
therapy. 

Hemiplegia following cerebral hemorrhage, 
physiotherapy in, 471 

Hemiplegia in children, physiotherapy 
in, 471 

Hemophilia, thyroid organotherapy in, 669 
Hemorrhage, treatment of, 48 

•-by blood transfusion, 48 

-by saline solutions, 48 

— uterine, 396 

-thermotherapy in. See Thermo¬ 
therapy. 

Hemorrhoids, hydrotherapy in, 427 

— physiotherapy in, 501 

Hepatitis, acute, thermotherapy in. See 
Thermotherapy. 

High-frequency current. See Electro¬ 
therapy. 

Histotherapy. See Organotherapy. 

Hives, thermotherapy in. See Thermo¬ 
therapy. 

Hodgkin’s disease, radium therapy in, 574 

— x-ray therapy in, 626, 627 
Hormone. See Organotheraneutics. 
Hormone substance, 636, 637 

Hormone therapy. See Organotherapeu¬ 
tics. 

Hydrotherapy, baths, 415 

-ablution, 415, 416 

-indications, 416 

-affusions, 417 

-effect of, 417 

-- Brand bath, 420 

— — cold plunge, 420 

-cold rub, 418 

-cold sponge, 418 

-drip sheet, 417 

-effect of, 418 

-elbow, 423 

—-—full bath, 420 

-in typhoid fever, 420 

-half-bath, 416, 417 

-hammock, 421 

-effect of, 422 

-equipment, 421 

—•-nervous disorders and, 422 

-preparation of patient, 422 



816 


INDEX 


Hydrotherapy, baths, hammock, septic 
conditions, and, 422 

--—contra-indications, 422 

-hot-air, 423 

-effect of, 423 

-Irish-Roman, 423 

-Russian, 423 

-sheet, 417 

--—effect of, 417 

-sitz, 422, 423 

-steam, 423 

-effect of, 423 

-warm, full, 421 

-effect, 421 

--—indications, 421 

— Brand bath, 420, 442 

— circulatory diseases and, 425 
•—•—arteriosclerosis, 426 

-endocarditis, 426 

-acute, 426 # 

-chronic, 427 

-pericarditis, acute, 427 

— cold, 410 

-application of, 410 

-effect on, 4l2 

- 1 -blood, 411, 412 

-blood-pressure, 411 

-breathing, 410 

-heart, 411 

-kidneys, 411 

-muscles, 410, 411 

-tissues, 410 

-intermediate response, 412 

-local, 420, 424, 425 

-remote general action, 412 

-cold stimulus, 412 

— compress, 419 

-abdominal, 419 

-combination, 420 

-Neptune girdle, 420 

-wet, 419 

— constitutional disorders and, 429 
-anemia, 429 

-'Chlorosis, 429 

— douches, 422 
-forms of, 422 

— gall-bladder, diseases and, 435 

— gall-stones and, 435 

— gastric diseases and, 437 

-acute gastric catarrh, 437 

-atony of stomach, 437 

--chronic gastritis, 437 

-■ dilatation of stomach, 437 

-dyspepsia, 437 

-gastroptosis, 437 

-ulcer, stomach, 437 

-compresses, 438 

-sitz baths, 438 

— gastro-intestinal tract and, 435 

-appendicitis, acute, 436 

-cholelithiasis, 435 

-constipation, 435 

-atonic, 435 

-spastic, 435 

- diarrhea, 436 

-enteric diseases, 435-437 


Hydrotherapy, gastro-intestinal tract 
and, enteritis, acute, 436 
-peritonitis, general diffuse, 436 

— general indications for, 424 

— genito-urinary diseases and, 432 
-amenorrhea, 434 

-bladder diseases, 432 

-cystitis, 432 

-dysmenorrhea, 434 

-endometritis, chronic, 434 

-enuresis, 432 

-epididymitis, 435 

-gonorrhea, acute, 433 

-kidney diseases, 432 

-menorrhagia, 434 

-metritis, chronic, 434 

-nephritis, acute, 432 

-nephritis, chronic, 432 

-baths in, 433 

-circular douche, 433 

-packs, 433 

-orchitis, 435 

-ovarian diseases, 434 

-prostatitis, 433, 434 

-salpingitis, acute, 434 

-uremia, 433 

— heat, 413 

-application of, 413 

-as general sedative, 413 

-action, 413 

-effect on, 413 

-muscles, 413 

-respiration, 413 

-local, 424 

-contra-indications, 424 

-effects, 413 

— hemorrhoids and, 427 

— hepatic hyperemia and, 435 

— history of, 405-407 

— ice-bag, 423 

— ice rub, 424 

— infectious diseases, specific and, 438 
-Asiatic cholera, 441 

-cerebrospinal meningitis, 443 

-hammock bath, 444 

-routine treatment, 444 

-cholera infantum, 441 

-diphtheria, 438 

-dysentery, 442 

-exanthemata, 438 

-measles, 438 

-scarlatina, 439 

-influenza, 438 

-malaria, 443 

-pneumonia, 444 

-pulmonary tuberculosis, 440 

-Cornet method, 440, 441 

-routine treatment in, 440 

-syphilis, 439 

-tetanus, 440 

-typhoid fever, 442 

-yellow fever, 441 

— intoxications and, 449 

-alcoholism. 452 

-acute, 452 

-chronic, 452 



INI 

Hydrotherapy, joint diseases and, 450 

-acute articular rheumatism, 451 

-arthritis deformans, 450 

—- — gonorrheal arthritis, 450 
-rheumatoid arthritis, 450 

— Leiter coil for application of ice, 423 

— metabolic disorders and, 431 

-chronic articular rheumatism, 431 

-diabetes insipidus, 429 

--diabetes mellitus, 429 

-exophthalmic goiter, 430 

-gout, 431 

-muscular rheumatism, 432 

-types of, 432 

-obesity, 430 

— Neptune girdle, 420 

— nervous disorders and, 444 

-cerebral anemia, 444 

-cerebral hemorrhage, 445 

—• — cerebral hyperemia, 445 
-chorea, 445 

-epilepsy, 445 

-headache, 445 

-hemicrania, 445, 440 

-hysteria, 440 

-infantile paralysis, 440, 447 

-- insomnia, 447 

-mania, 450 

-myelitis, 447 

-acute, 447 

-chronic, 448 

— —neuralgia, 448 

— — neurasthenia, 448 

-routine treatment in, 448 

-neuritis, 448, 449 

— —occupation neurosis, 449 
-paralysis, 449 

-spasmodic tic, 450 

-tabes dorsalis, 449 

— osmosis, 414 

— — mechanism of, 414 

-principle in treatment of wounds, 

414, 415 

— pack, 418 

-ice, 424 

-wet, 418, 419 

-wet blanket, 419 

— references, 409, 470 

— respiratory diseases and, 427 

-acute bronchitis, 428 

-asthma, 427 

-edema of lungs, 428 

-hyperemia of lungs, 428 

--pleurisy, 428, 429 

— saline solution in treatment of wounds, 
415 

— surgery and, 415 

— toxemias and, 449, 452 

-arsenic poisoning, chronic, 452 

-mercurialism, chronic, 452 

-morphinism, chronic, 452 

—• — nicotinism, chronic, 452 

-plumbism, chronic, 452 

-thermic fever, 452, 453 _ 

— water, 408 

-as electrical conductor, 408 


Hydrotherapy, water, as medium for ap¬ 
plication of cold, 408 

-as medium for application of heat, 

408 

-as solvent, 413, 414 

-as vehicle for drugs, 414 

-effect on skin, 409 

-mechanism, 409, 410 

-mode of application, 415-424 

-factors governing, 416 

-osmotic pressure of, 414 

-physiological action on skin, 409 

-properties of, 408-410 

-use of, 414 

— --in septic conditions, 414 

-in shock, 414 

- See also Physiotherapy; Thermo¬ 
therapy. 

Hyperadrenia, organotherapeutics in, 714, 
715 

Hyperemia. See Thermotherapy. 
Hyperfunction, primary, unaffected by 
organotherapy, 637, 638 
Hyperidrosis, x-ray therapy in, 617, 618 
Hyperpituitarism. See Organotherapeu¬ 
tics, 733-735 

Hyperthyroidism, clinical, 656-659 

— experimental, 656-659 

— theories of, 656-659 

— x-ray therapy in, 625, 626 
Hypertrichosis, x-ray therapy in, 618 
Hypo-adrenia, organotherapeutics in, 714, 

715 

Hypochloriiydria, thermotherapy in. See 
Tliermotherapy. 

Hypophysis, in organotherapeutics. See 
Organotherapeutics. 

Hypophysis cerebri. See Hypophysis. 
Hypopituitarism. See Organotherapeu¬ 
tics, 735-737 

Hypotension, physiotherapy in, 491, 492 
Hypothyroidism, in adult, 662 

— in childhood, 659-662 
Hysteria, hydrotherapy in, 446 

Infantile paralysis. See Paralysis. 
Infantile uterus. See Uterus. 
Infectious diseases, specific, hydrother¬ 
apy in. See Hydrotherapy. 
Infundibular body. See Posterior lobe. 
Inorganic substances. See Nutrition and 
Dietetics. 

Insolation. See Climatology. 

Insomnia, hydrotherapy in, 447 
Insulin. See Organotherapeutics. 
Intermittent claudication, 494 
Intoxication, concentration in, 56 

— theory of, 56 

— water in, 56 

Intoxications, hydrotherapy in. See Hy¬ 
drotherapy. 

Iodin, in thyroid gland, 650, 651 
Ionic medication. See Ionization. 
Ionization. See Electrotherapy. 

Ions, action of, 30 

— anions, 10 





818 


INDEX 


Ions, aniens, definition of, 10 

— cations, 10 

-definition of, 10 

— effects on protoplasm, 30, 31 

— formation of, 30 

— See also Ionization. 

Islands of Langeriians. See Organo- 
therapeutics, pancreas. 

Isotonic coefficients. See Coefficients. 
Isotonic solutions. See Solutions. 

Joints, diseases of, hydrotherapy in, 450 

— See Physiotherapy. 

Keloid, radium therapy in, 570 

— x-ray therapy in, 613 
Keratoses, radium therapy in, 569 
Kidney, organotherapy in. See Organo- 

therapeutics. 

— x-ray therapy in, 591 

Kidney disorders, climatic treatment of, 
206 

Kyphosis, physiotherapy in, 530, 531 

Langerhans, islands of. See Organo- 
therapeutics, pancreas. 

Laryngitis, physiotherapy in, 503 

— tuberculous, 205 

-climatic treatment of, 205 

Larynx, effect of x-ray therapy on, 592 
Leiter coil. See Hydrotherapy. 
Leukemia, radium therapy in, 558-560 

— x-ray therapy in, 627, 628 
Leukoderma, physiotherapy in, 517 
Leydig’s cells, 757 

Lichen planus, radium therapy in, 570 

— x-ray therapy in, 605, 606 
Light-therapy. See Phototherapy. 

Liver, cirrhosis of, thermotherapy in. 

See Thermotherapy. 

— in parathyroid tetany, 677 
Lordosis, physiotherapy in, 531 
Lungs, edema of, 428 

-hydrotherapy in, 428 

— x-ray therapy in, 591 

Lupus erythematosus, physiotherapy in, 
517 

— radium therapy in, 570 

— x-ray therapy in, 608 

Lupus vulgaris, physiotherapy in, 517 

— radium therapy in, 570-571 

— x-ray therapy in, 608 
Lutein. See Corpus luteum. 

Lymph-gland therapy. See Organothera- 

peutics. 

Lymphoma, radium therapy in, 574 

Malaria, hydrotherapy in, 443 

— x-ray therapy in, 631 

Mammary gland, in organotherapy. See 
Organotlierapeutics. 

Mania, hydrotherapy in, 450 
Massage. See Physiotherapy. 

Mastitis, chronic, x-ray therapy in, 622 
Mastoiditis, thermotherapy in. See Ther¬ 
motherapy. 

— x-ray therapy in, 629, 630 


Meat extracts, juices and powders. See 
Nutrition and Dietetics. 
Mechanotherapy, ankle and, 257 

-circumduction of, 257 

-dorsifiexion of, 257 

— apparatus, 240-260 

-requirements of, 250, 251 

-types of, 240-260 

— as an adjuvant, 241 

— development of, 240 

— elbow, 255 

-extension and flexion at, 255 

— exercise, 241 

-conditions requiring general, 262 

-conditions requiring local, 262, 263 

-contra-indications, 262 

-indications for, 261, 262 

-mensuration in, 259-261 

-apparatus, 259, 260 

-purposes of, 241 

-therapeutic effect on, 241-243 

-digestion, 243 

-genito-urinary system, 244 

-metabolism, 244 

-muscles, 245, 246 

-nervous system, 243, 244 

— fingers and, 252, 253 

— foot and, 257 

-dorsifiexion of, 259 

-eversion and inversion, 257 

-plantar flexion of, 259 

— gymnastics, 246 

-classification of movements, 246 

-general exercises, 247, 248 

-passive movements, 248, 249 

-positions in, 248, 249 

— hip and, 258 

-abduction and adduction of, 258, 259 

-extension and flexion of, 259 

— history of, 240, 241 

— knee and, 257 

-extension and flexion of, 257-259 

-rotation of, 257 

— muscles and, 245, 246 
-physiology of, 245 

— references, 263 

— thigh and, 259 

-extension of, 259 

-flexion of, 259 

— thumb and, 253 

-abduction and adduction of, 253 

— wrist and, 253 

-abduction and adduction of, 254, 255 

-extension and flexion of, 255 

-pronation and supination of, 255 

-stretching of, 253 

Melanoma, x-ray therapy in, 615 
Membrane, cellular, 56 

— definition of, 60 

— interference, in distribution, 28, 29 
Meningitis, cerebrospinal, hydrotherapy 

in, 443 

Menopause, artificial, radium therapy 
in, 581 

Menorrhagia, radium therapy in, 580 

— x-ray therapy in, 622 



INDEX 


819 


Mensuration, in gymnastics. See Mech¬ 
anotherapy, 259-261 
Mesothorium. See Radium. 

Metabolism, disturbances of, 193, 194, 429 

— in fever. See Nutrition and Diabetics. 

— thermotherapy in. See Thermotherapy. 

— See also Nutrition and Dietetics. 
Metrorrhagia, radium therapy in, 580 
Mineral springs. See Balneology. 

Mineral waters. See Balneology. 

Miners’ consumption, 200 

Motor neuron lesions, physiotherapy in. 

See Physiotherapy. 

Mountain sickness, 193, 194 

Mouth, diseases of, physiotherapy in, 498 

— radium therapy in, 573 
Muscle nerve testing, 477-480 
Mycosis fungoides, x-ray therapy in, 608, 

609 

Myocarditis, physiotherapy in, 494 

— thermotherapy in. See Tliermotherapy. 
Myositis, physiotherapy in, 483, 484 
Myxedema, organotherapy in, 662, 663 

Nephritis, physiotherapy in, 524 

— thermotherapy in. See Thermotherapy. 
Neptune girdle. See Hydrotherapy. 
Nervous disorders, climatic treatment of, 

206, 207 

— hydrotherapy in. See Hydrotherapy. 

— thyroid organotherapy in, 669 
Nervous system, effect of x-ray therapy 

in, 591 

Neuralgia, hydrotherapy in, 448 
Neurasthenia, hydrotherapy in, 448 

— physiotherapy in, 483 
Neuritis, physiotherapy in, 482, 483 

— thermotherapy in. See Thermotherapy. 

— x-ray therapy in, 630, 631 
Neurohypophysis. See Posterior lobe. 
Neuromuscular system, diseases and in¬ 
juries of, physiotherapy in, 471 

Nevt, physiotherapy in, 517 
Non-electrolytes, 959 

— effects of, on protein colloids, 34 
Nose, diseases of, radium therapy in, 573 
Nutrition and Dietetics, artificial feeding, 

120 

-methods of, 120 

-gavage, 122, 123 

-rectal, 120-122 

-subcutaneous, 123, 124 

— beverages, 128 

-purin content of, 128 

— caloric intake, 88 

-in various groups, 88, 89 

— calory, 85 

-definition of, 85 

— carbohydrate requirement, 93, 94 

— condiments, 82 

-classification of, 82 

— diet, 124 

-fever and, 134 

_carbohydrate requirement, 135 

-fat requirement, 135 

-milk in, 135 


Nutrition and Dietetics, diet, fever and, 
protein requirement, 135 

-total energy requirement, 134, 135 

-useful foods in, 136 

-invalid’s, 136 

-foods permitted, 136-143 

-- — caloric value, 136-143 

-purin-free, 127 

-salt-poor, 124 

-classification of, 124 

-in disease, 125 

— dietary standards, 88, 89 

— dietetics, 69 
-definition of, 69 

— fat requirement, 93 

-injurious effects of excess, 93, 94 

— food, 85 

—■—absorption of, in fever, 134 

-total requirement, 85 

-methods to determine, 85 

— foods, 84 

-acid-forming, 84 

-classification of, 84 

-effects of, 83 

-table showing, 84 

-base-forming, 84 

--—classification of, 84 

-effects of, 83 

-table showing, 84 

-composition of, 96 

-table showing, 96-104 

-digestibility of, 113 

-carbohydrates, 113, 114 

-eggs, 111, 112 

-fat, 114, 115 

-fish, 111 

-meats, 110, 111 

-milk, 112, 113 

-poultry, 111 

-effects of cooking upon, 104-107 

-cereals, 107 

-flour, 107 

-meats, 106 

-vegetables, 106 

-fuel value of, 69 

-infants’, 146 

-analyses of, 146-149 

-tables showing, 146-149 

-invalids’, 146 

-analyses of, 146-149 

-tables showing, 146-149 

-length of time in stomach, 115-117 

-medicinal, 150 

-analyses of, 150 

-nutritive value of, 108 

-proprietary. 143 

-bases, 143 

-composition, 144 

-meat extracts, 144 

-fluid, 144 

-analvses, 144, 145 

-solid, 144, 145 

-analyses of, 144, 145 

-uses of, 143 

-value of, 143 

-vitamin deficiency in, 144 





820 


INDEX 


Nutrition and Dietetics, foods, purin con¬ 
tent of, 127, 128 

-salt content of, 125-127 

-— tables showing, 125-127 

-uses of, 71 

-vitamin content of, 77-81 

-tables showing, 77-81 

— foodstuffs, 70 

-classification of, 70 

-carbohydrates, 70 

-uses, 72 

-fats, 70 

-uses, 72 

-inorganic substances, 71 

-proteins, 70 

---adequate, 71, 72 

-inadequate, 71, 72 

-uses, 71 

-vitamins, 71 

— gluten flour, 105 
-composition of, 105 

— meat juices, 145 

--analyses of, 145 

-composition of, 145 

--nutritive value of, 145 

— meat powders, 145 
-analyses of, 145 

— metabolism, 85 
-in fever, 131 

-nitrogen metabolism, 131-133 

-qualitative changes, 130, 131 

-quantitative changes, 129, 130 

-total metabolism, 128 

-rate of, 86, 87 

— nutrition, 69 
-definition of, 69 

— overfeeding, 119 
-effects of, 119, 120 

— protein requirement, 90 

-amount of, 90, 91 

-in disease, 91, 92 

-injurious effects of excess, 92 

-standards of, 90, 91 

-variations in, 91, 92 

— purins, forms of, 127 

— references, 151-153 

— salts, uses of, 73 

— standard rations of, 95 

-carbohydrate, 95 

-fat, 95 

-protein, 95 

— starvation, 117 

-complete, 117 

-effects of, 117, 118 

-partial, 118 

-effects of, 118 

— total energy requirement, 86 
-adult, 89, 90 

-factors influencing, 86 

-age, 87 

-muscular activity, 87 

-size of individual, 87 

— vitamin diet, 76 

•-selection of, 76-81 

-tables showing, 77-81 

— vitamins, 74 


Nutrition and Dietetics, vitamins, classi¬ 
fication of, 74 

-distribution of, 75, 76 

-effect of lack, 74-76 

-occurrence of, 75 

-properties of, 75, 76 

— water, uses of, 73 

Obesity, faradism in. See Electrotherapy. 

— hydrotherapy in, 430 
Occupational therapy, 264 

— agencies promoting, 266, 267 

— application of, 208, 276-278 

— basic principles of, 267, 268, 279 

— definition of, 267 

— development of, 264-268 

— disabled and crippled and, 266 
—ergotherapv, 267 

-definition of, 267 

— functional reeducation, 267 

-definition of, 267 

-purpose of, 267 

— hospitals and, 265, 266 

— manual work as therapeutic agent in, 
264, 265 

— nervous disorders and, 265 
-early recognition of, 265 

— purposes of, 267 

— references, 280 

— rehabilitation therapy, definition of, 268 

— remedial work, 268 

-ambulatory cases and, 271-274 

-bedridden cases and, 268-270 

-types of, 268-279 

— sanitariums and, 266 

— selection of suitable work, 268 

— stimulus by World War, 266 

— synonyms of, 267 

— types of work in. 265, 266 

— vocational rehabilitation, 268 
-definition of, 268 

-governmental, 266 

-appropriation for, 266, 267 

— vocational training, 268 

-application of, 276-278 

-articles produced, 278 

-kinds of, 278 

-director of. 276 

-qualifications of. 277 

-equipment for, 274, 276 

-financing of, 278 

-space required for, 278 

-types of patients to be trained, 277 

— See also Physiotherapy. 

O’Dwyer treatment, in thermic fever, 453 
Opotherapy. See Organotherapy. 
Organotherapeutics, 633 

— blood in, 777 

-hemoglobin feeding, 779 

-leukocytic extracts, 778 

-action of, 778, 779 

-effects of, 778, 779 

-therapeutic uses of, 778, 779 

-references, 807 

-transfusion of, 777 

-benefits of, 777, 778 



INDEX 


821 


Drganotherapeutics, blood in, transfusion 
of, effects of, 778 

-in anemia, 778 

-value of, 778 

— clinical control in, 642 

— clinical organotherapy, 646 

— complete organotherapy, 647 

— dangers of intravenous, 643 

— definition of, 633, 634 

— development of*, 635, 636 

— duodenal mucosa and, 772 
-references, 806 

-secretin, 772 

-a drug, 777 

-fate of, in gut, 772 

-preparation of, 772 

-secretin organotherapy, 773 

-in diabetes mellitus, 773, 774 

--results of, 774 

— dystrophy and, 638 
-effect in, 638 

— endocrine hypofunction and, 643 

— endocrine therapy in, 643 

-pluriglandular, 644, 645 

-uniglandular, 644, 645 

— experimental organotherapy, 646, 647 

— fetus and, 753 
-references, 801 

— gastric mucosa and, 776 

-gastrin, 776 

-a drug, 777 

-preparation of, 776 

-proprietary preparations of, 776 

-gastro-intestinal motor hormone, 774 

-cholin, 774, 775 

-hormonal, 774, 775 

-references, 806 

— general principles of, 636 

— gland transplantation in, 634 

— glandular products for, 635 

— history of, 633-636 

— hormone, 636 

—■ — accumulation of, 638, 639 

-activity of, 640, 641 

-antagonism between ovarian and 

testicular, 747, 748 

-destruction by enzymes, 640 

-stability of, 639, 640 

— hormone substance, 636 
-action of, 637 

— hyperfunction and, 637, 638 
hypophysis, 723 

-accessory, 723, 724 

-anterior lobe of, 720 

-effect on growth, 732 

-effect on sexual maturation, 732 

—■-extirpation of, 729, 730 

-effects of, 729, 730 

-extract, 731 

_effects of experimental feeding, 

731, 732 

-function, 729 . 1 

-crowth-controlling principle, 7^9 

_tetlielin, 729 

-therapeutic uses of, 737, 738 

-development of, 723, 724 


Organotherapeutics, hypophysis, direct 
stimulation of, 730, 731 

-extract of, 724 

-action on blood-pressure, 725 

-kidneys, 725, 726 

-muscle, 724 

-nerves, 725 

-functional disorders of, 733 

-hyperpituitarism, 733-735 

-acromegaly, 733, 734 

-gigantism, 734 

-•hypopituitarism, 735-737 

-symptoms of, 736, 737 

-histology of, 720-722 

-pars intermedia, 724 

-function of, 724 

-pharyngeal, 723 

-pituitrin, 728. See also Posterioi 

lobe. 

-posterior lobe, 724 

-active principle, 727 

-chemistry, 727, 728 

-commercial preparation, 728 

-pituitrin, 728 

-daily injections, 727 

-effect on respiratory center, 727 

-extract, 726, 727, 736 

-action, 726, 727 

-effect on blood-pressure, 736 

--galactagogue action, 726 

-standardization, 728 

-feeding experiments with, 728, 729 

-results, 728 

-function of, 724 

-pressor substance in, 727 

-therapeutic uses of, 739, 740 

-references, 796-799 

-removal of, 735 

-effect of, 735 

-secretory nerves of, 731 

-structure of, 720, 721 

-summary, 737-740 

•-transplantation of, 730 

-effects of, 730 

— insulin, 641, 696-699 

— intestinal mucosa and, 775 

-possible hormone, 775 

-functions, 775, 776 

— kidney and, 780 
-extracts of, 780 

-commercial preparations, 780 

— liver and, 781 

-effect of extirpation, 781 

-preparations of, 780, 781 

— lymph glands and, 779 

— mammary gland and, 754 
-references, 801, 802 

— medieval and ancient organotherapy, 635 

— organ extracts, various, 781, 782 
-therapeutic uses of, 781, 782 

— organ transplantation, 633, 634 

— ovaries and, 740 

-anatomy of, 740 

-atrophy of, 741 

-congenital absence of, 741 

-corpus luteum, 741, 745 




822 


INDEX 


Organotherapeutics, ovaries and, corpus 
luteum, amenorrhea and, 750, 751 

-menopause and, 741), 750 

-menorrhagia and, 751 

-proprietary preparations, 752 

— -luetin, 752 

-role of, 745-747 

-therapeutic uses, 749-751 

-results, 749 

-extirpation of, 741, 742 

-extracts of, 748 

-administration, experimental, 748, 

749 

-causes of failure, 751, 752 

-chemistry, 743, 745 

-preparations of, 748-752 

-administration, 752 

-preparation, 752 

-therapeutic use, 749-751 

-references, 800, 801 

— •—summary, 752, 753 

-transplantation of, 743 

-clinical, 743 

-results, 743 

-experimental, 742 

-results, 742 

— pancreas, 685 

-diabetes, clinical, 699 

-blood transfusion in, 691, 699 

-effects, 691, 699 

-relation of other endocrines to, 

699, 700 

-treatment, 701 

-dietary, 701 

-insulin in, 701 

-experimental, 699 

-acidosis in, 688, 689 

-carbohydrate tolerance in, 

690, 691 

-glycosuria in, 688 

-hyperglycemia in, 688 

-metabolism in, 689 

-polyphagia in, 689 

-respiratory quotient in, 689, 

690 

---sugar tolerance in, 689. 690 

-relation of other endocrines to, 

699, 700 

-relation to clinical diabetes, 

697 

-theories of, 691 

-extirpation of, 685 

-effects, 685, 686, 688-691 

-extracts of, 695 

-feeding, 695 

-effects, 695 

-injection, 695 

-effects, 695 

-insulin, 696 

-administration, 696 

-hypodermatic, 699 

-results, 699 

-in clinical diabetes, 698 

-oral administration, 698 

-effects, 698, 699 

-toxicity, 696, 699 


Organotherapeutics, pancreas islands of 

Langerhans, 686-688 

-histology, 687, 688 

-number and size, 687 

-in man, 687 

-parabiosis, 693 

-effect, 693 

-preparations of, 699 

•-intravenous injections, 699 

-subcutaneous injections, 699 

-references, 791-793 

-summary, 701 

-transplantation of, 694 

-results, 695 

-technic, 695 

— pancreatectomy, 688 

-effects of, 688 

-complete, 689 

-in pregnancy, 693, 694 

-partial, 689 

— pancreatic perfusates, 696 
-action of, 697 

-effects of, 697 

-hormones in, 696, 697 

— parathyroids, 674 

-administration of, 680 

-oral, 680 

-deficiency, in man, 682 

-symptoms of, 682 

-effects of, 684, 685 

-in gastric tetany, 684 

-in paralysis agitans, 684 

-postoperative tetany, 683 

-extirpation of, 675 

-effects, 675, 681 

-tetany following, 675, 676 

-typical symptoms following, 675 

-histology of, 674 

-physiology of, 674 

-references, 788-791 

-summary, 684, 685 

-tetany, 682 

-control of, 683 

-digestive disorders in, 676, 677 

— -experimental, 679 

-cause of, 681 

-control of, 679 

-permanent, 680, 681 

-temporary, 679 

--‘forms of, 682 

-in children, 682, 683 

-transplantation of, 680 

— pineal body, 762 

-atrophy of, 762 

-extirpation of, 763 

-effects, 763 

-extracts of, 763 

-injections, 763 

-- — effect, 763 

-pineal material, 763 

-feeding, 763 

-effects, 763, 764 

-references, 803, 804 

-structure of, 762 

-tumors of, 764 

-symptoms, 764 














INDEX 


823 


Organotherapeutics, pituitrin, 739 

-therapeutic uses of, 739 

-effects, 7 39 

— placenta, 753 
-references, 801 

-— pluriglandular, 644-646 

— preparation of products, 642 

— principles of, 633, 634 

— prostate gland, 761 

-feeding of, 761 

-effects, 761, 762 

-references, 803 

-secretion of, 761 

-summary, 762 

— rational, 636 

-Brown-Sequard, 636 

-effect on biological investigation, 636 

-effect on clinical practice, 636 

— references, 782, 783 

— spleen, 768 

-dysfunction of, 770 

-Hanot’s cirrhosis, 770 

-hemolytic jaundice, 770 

-pernicious anemia, 771 

-splenic anemia, 770 

-extracts of, 769 

-experimental administration, 769, 

770 


-therapeutic uses of, 771 

-physiology of, 768, 769 

-references, 805, 806 

— splenectomy, 769 
—- — effects of, 769 

-in normal subjects, 769 

-on blood, 769 

— standardization of products, 641 
-importance of, 641 

— summary, 782 

— suprarenals, 701 

-Addison’s disease, 714, 715, 720 

-etiology, 720 

-symptoms, 714 

-adrenal cortex, 712, 719 

-deficiency, 715 

-function, 705, 712, 719 

-emergency theory, 705 

-tonus theory, 704 

-therapy, 720 

-adrenalin. See Epinephrin. 

-anatomy of, 701-703 

-deficiency in man, 715 

-disease of, 714 

-epinephrin, 703 

-contra-indications to use, 719 

-control of blood capillaries, 706 

— -dosage, 718, 719 

-effect on blood-pressure, 704, 705 

-normal output, 704 

— -normal secretion, 703 

— -rate of, 703 

— --pharmacological actions on, 707- 


-alimentary tract, 708, 709 

-blood-vessels, 707, 708 

-bronchial muscles, 710 

-coronary circulation, 708 


Organotherapeutics, suprarenals, epi¬ 
nephrin, pharmacological actions of, 
eye, 710 

-heart, 708 

-kidneys, 710, 711 

-metabolism, 711-712 

-urinary bladder, 709 

-uterus, 709, 710 

-uses as, 716-718 

-cardiovascular stimulant, 

716, 717 

-local hemostatic, 716-718 

-synergist, in local anesthe¬ 
sia, 718 

-proprietary names, 718, 719 

-secretion, 706, 707, 719, 720 

-stability, 704 

-untoward effects, 719 

-extirpation of, 712 

-effects, 712, 713 

-extracts of, 703 

-adrenalin, 703 

-epinephrin, 703 

-hyperadrenia, 714 

-hypo-aurenia, 714 

-definition, 714 

-insufficiency, 715 

-supposed conditions, 715, 716 

-medullary tissue of, 703 

-chemistry, 703, 704 

-references, 793-796 

-summary, 719, 720 

-transplantation of, 715 

— synonyms of, 633 

— testes, absence of, 755 

-atrophy of, 755 

-chemistry of, 758 

-extirpation of, 755 

-effects, 755-757 

-extracts of, 758 

-clinical uses, 759 

-experimental uses, 758 759 

-interstitial cells, 757 

-function, 757 

— --relation to cortical cells of ad¬ 

renals, 758 

-limitation in use of, 761 

-references, 802, 803 

-summary, 761 

-transplantation of, 759-761 

-results of, 760-761 

— thymus, 764 

-cells, types of, 764 

-effect on growth, 765, 766 

-extirpation of, 766 

-effect, 766 

-extracts of, 767 

-therapeutic uses, 767, 768 

-results, 767, 768 

-function of, 767 

-Graves’ disease, 766 

-involution of, 764 

-pathology of, 767 

-physiology of, 764-767 

-references, 804, 805 

-role of, 765 





824 


INDEX 


Organotherapeutics, thymus, summary, 

708 

— thymectomy, 700 

-results of, 700 

-—thyroid, 048 

-administration of, 063, 672 

-contra-indications, 072, 673 

-general indications, 070 

-methods, 070 

-oral, 671 

-subcutaneous injections, 670 

-transplantation, 070 

-untoward effects, 672, 673 

-chemistry of, 050 

-iodin, 650, 651 

-thyrotoxin, 051, 652 

-commercial preparations of, 653 . 

-iodin content, 653 

-average, 653 

-cretinism, 660 

-administration of thyroid in, 660, 

661, 663, 664 

-spontaneous, 661 

-in animals, 661 

-in man, 661 

-deficiency in childhood, 659, 660 

-detoxication in, 654 

-effect in, 667 

-hemophilia, 669 

■ -menstrual disorders, 669 

-nervous disorders, 669 

-normal individuals, 667 

--—rickets, 669 

— --skin diseases, 668 

-effect of iodin on, 652, 653 

-effect of removal, 659 

-effect of thyroid feeding, 658 

-extirpation of, 648 

•—--effect, 648 

-function of, 648, 649 

-histological structure of, 655 

-relation of iodin to, 655 

-hyperplasia, 656 

-relation of thyroid to, 656 

-hyperthyroidism, 656 

-clinical, 656 

-experimental, 656 

-goiter, toxic, 656 

-cause, 657-659 

- decrease of colloid, 657 

-hyperplasia, 657, 658 

— --hypersecretion, 657 

-increased metabolism, 658 

-symptoms, 657, 658 

-theories of, 657-659 

-compensatory hypertrophy, 658, 

659 

-perverted secretion, 658 

-hypothyroidism, in adult, 663 

-administration of thyroid, 663- 

665 

-effects, 663 

-manifestations, 662 

■ -'—myxedema, 662 

-pathological changes, 662 

-symptoms, 662 


Organotherapeutics, thyroi d, hypo¬ 
thyroidism, in adult, myxedema, thyroid 
therapy, 663 

-in childhood, 659 

-cretinism, 659-662 

-mild, 665 

-conditions due to, 665, 666 

-thyroid therapy, 666 

-iodin content of, 653, 654 

—<*-form, 653 

-increase, 654 

-standardization, 653 

-indications for use of, 667-669 

-injuries to, 660 

-effect, 660 

-innervation of, 649 

-significance, 649 

-insufficiency, 660 

-mental development and, 660 

-physical development and, 660 

-neoplasm, 656 

-relation of thyroid hyperplasia to, 

656 

-physiologic activity in relation to 

iodin, 652, 653 

-preparations of, 653 

-commercial, 653 

-extracts, 672 

-official, 671 

-references, 784-788 

-relation to diet, 653, 654 

-secretion of, 654 

-body fluids and, 655, 656 

-success of organotherapy in, 648 

-summary, 673, 674 

— thyroidectomy in, 661 

-adult, 663 

-effect of, 663 

-young, 661 

-effect on sexual maturation, 662 

— uniglandular, 644-646 
Organotherapy. See Organotherapeutics. 

Osmosis, 56 

— absorption theory, 57 

— isosmotic solutions, 58 

— isotonic coefficients, 58 

— isotonic solutions, 58 
-definition of, 58 

— membrane, 57, 59, 60 

-definition of, 60 

-theory of, 59, 60 

— osmotic cells, 57 

— osmotic pressure, 56-59 

-laws of, 58, 59 

-theory of, 57 

— precipitation membrane, 57 
-example of, 57, 58 

-relation to osmotic membrane, 58 

— secretory theory of, 57 

— surface tension films, 60 

— See also Hydrotherapy. 

Osteomyelitis, phvsiotherapy in, 486, 

487 

— tuberculous, 629 

-x-ray therapy in, 629 

— ultraviolet ray in. See Thermotherapv. 








INDEX 


825 


Otitis media, acute, thermotherapy in. 
See Thermotherapy. 

— chronic, thermotherapy in. See Ther¬ 
motherapy. 

— physiotherapy in, 527 

Oudin current. See Electrotherapy. 
Ovarian preparations, in organotherapy, 
749-751 

Parathyroid organotherapy. See Organo- 
therapeutics. 

— x-rays, effect on, 593 

Ovaritis, thermotherapy in. See Thermo- 
therapy. 

Overfeeding. See Nutrition and Dietetics. 

Packs. See Hydrotherapy. 

Pancreas. See Organotherapeutics. 
Pancreatectomy, effects of, 688-691 
Pancreatic extracts, in diabetes, 696- 
699 

Papillomata, radium therapy, 569 
Parabiosis, experimental, in pancreatic 
diabetes, 693 

Paralysis, infantile, hydrotherapy in, 
446, 447 

— physiotherapy in, 472, 477 

Parathyroid organotherapy. See Organo¬ 
therapeutics. 

Parathyroids. See Organotherapeutics. 
Pars anterior. See Hypophysis. 

Pars intermedia. See Hypophysis. 

Pars nervosa. See Posterior lobe. 

Partition, laws of, 54 

Pelvic diseases, physiotherapy in, 522 

— radium therapy in, 577-581 

— thermotherapy in. See Thermotherapy. 
Periostitis, physiotherapy in, 487 
Peripheral nerve lesions, physiotherapy 

in. See Physiotherapy. 

Peritonitis, tuberculous, x-ray therapy 
in, 629 

Pertussis. See Whooping cough. 
Pharmacology, 11 

— comparative methods in, 11-14 

— ionic concentration, 13 
-principles of, 13, 14 

— molecular solution, 12, 13 
-definition of, 12 

— normal solution, 13 
-definition of, 13 

— standard solutions, 11-14 
Phlebitis, physiotherapy in, 492 
Phototherapy, apparatus, 333, 339 

— Finsen lamp, 333 

— heliotherapy, 327 

-contra-indications, 331 

-indications for, 331 

-length of exposure, 331 

-physiological effects of, 329 

-pigmentation in, 330 

-systemic effects of, 330 

-technic of application, 330 

— history of, 327 

— light, 327 

-absorption of, 329 

-classification of, 327 


Phototherapy, light, penetrability of, 
328 

-pigmentation by, 329 

— light vibrations, 327 
-classification of, 327, 328 

— physics of, 327, 328 

— Quartz lamp, 335 

— radiant light, 331 

-apparatus, 332, 333 

-carbon arc light, 333 

-contra-indications, 335 

-definition of, 331 * 

-general effects of, 333 

-local effects of, 332 

-technic of application, 334 

-therapeutic effect of, 332 

-therapeutic indications of, 334 

— ultraviolet rays, 327 

-absorption of, 329 

-apparatus, 338 

-applicators, 341 

-burners, 339, 343, 344 

-care of, 341, 342 

-lamps, 338, 339, 340, 342 

-air-cooled, 342 

-water-cooled, 345 

-bacteria, destructive dosage for, 346 

-contra-indications, 347 

-definition of, 335 

-effects of, 329 

-general, 337 

-local, 336, 337 

-physiological, 335, 336 

-history of, 335 

-in common types of light, 336 

-physics of, 335 

-precautions in use of, 346 

-technic of application, 343, 346 

-dosage, 343 

-destructive, 343 

-regenerative, 343 

-stimulative, 343 

-therapeutic indications of, 347 

-variation of, 336 

— x-ray, 328 

Physical education. See Physiotherapy. 
Physiochemical principles, 1 

— application of, 38, 39 

— colloidal state, 32 

— diffusion, 20 

— dissociation, electrolytic, 29 

— distribution, 22 

— equilibrium, 14 

— osmosis, 56 

— solutions, standard, 11 
Physiology, general, 5 

— special, 5 

Physiotherapy, agents employed in, 211 

— as an adjuvant, 212, 215 

— athletic injuries and, 214 

-muscle bruises, 214 

-sprains, 214 

-strains, 214 

— bones, 485 

-arthritis, 487 

-infectious, 489 





'826 


INDEX 


Physiotherapy, bones, arthritis, toxic, 
488 

-traumatic, 487 

-tuberculous, 489, 490 

-fracture of, 485 

-compound comminuted, 486 

-simple, 485, 486 

-fracture sprains, 486 

-osteomyelitis, 486 

-periostitis, 487 

-rickets, 486 

-tuberculous osteitis, 487 

— bones and joints, 490 

-combined conditions affecting, 490 

— cardiovascular diseases and, 490 
-anemia, 492 

-treatment, 492, 493 

-arteriosclerosis, 490, 491 

-cardiac disturbances, functional, 495 

-cardiovascular classes, 495 

-exercises, 495 

-in U. S. Army, 495 

-effort syndrome, 495 

-treatment of, 495 

-by graded exercise, 495-497 

-results, 497 

-Shott-Nauheim exercises in, 497 

-chlorosis, 492, 493 

-endarteritis obliterans, 492 

-heart, organic valvular lesion of, 493 

-effect of exercise, 493, 494 

-hypertension, 490, 491 

-hypotension, 490, 491 

-intermittent claudication, 494 

-results of treatment in, 494 

-myocarditis, 492 

-phlebitis, 492 

-Shott-Nauheim exercises in, 497 

— development of, 211, 212 

— diphtheria carriers, 503 

-ultraviolet light in treatment of, 503 

— ear, diseases of. 524, 527 

-catarrhal deafness, 527 

-otitis media, 527 

-treatment, 527 

— electrotherapy, 211 

-types of currents, 213 

-faradic, 213 

-galvanic, 213 

-high frequency, 213 

-interrupted, 213 

-Oudin’s high-frequency, 213 

-sinusoidal, 213 

-static electricity, 213 

-Tesla’s high-frequency, 213 

-wave galvanic, 213 

— exercise, 213 

-adolescent and, 232-234 

-adult and, 234 

-after-effects of, 230 

-available energy in, 228 

-body efficiency in, 228 

-cardiac output in, 229 

-effort syndrome in, 230, 231 

-fatigue in, 230 

-importance of, 227, 228 


Physiotherapy, exercises local blood sup¬ 
ply in, 229 

-oxygen consumption in, 228, 229 

-physiological effects of, 239 

-physiology of, 228-231 

-factors in, 228-231 

-pulse acceleration in, 229 

-setting-up, 234, 235 

-training, 229, 230 

-types of, 231, 232 

— foot disabilities, 535 
-arch, 538 

-treatment, 538, 539 

-causes of, 536 

--—improper shoes, 536 

-role of disease, 537 

-classification of, 535 

-diagnosis of, 537, 538 

- foot strain, 538 

-muscle-bound feet, 539 

-treatment of, 538 

-corrective shoes, 538 

-electricity, 538, 539 

-radiant light, 538 

-removal of foci of infection, 538 

— gastro-intestinal diseases and, 498 
-anal fissure, 501 

-apical abscess, 498 

-appendicitis, 498 

-cholecystitis, 498 

-constipation, chronic, 499 

-electrotherapy, 500 

-exercise, 500 

-massage, 500 

-duodenal ulcer, 499 

-gastric ulcer, 499 

-gastritis, 498 

-hemorrhoids, 501 

-pyorrhea, 498 

-ultraviolet ray in, 498 

-x-ray in, 498 

-sigmoid impaction, 500, 501 

— general considerations in, 218 

— genito-urinary diseases, 519 

-amenorrhea, 519 

-diathermy in, 519, 520 

-cervical erosions, 521 

-dysmenorrhea, 520 

-diathermy in, 520 

-exercise in, 520 

— — endometritis, 520 

-ionization in, 521 

-enuresis, 523 

-electricity in, 523 

-gonorrhea, 523 

-diathermy in, 523 

-ionization in, 523 

-radiant light in, 523 

— — infantile uterus, 522 

-nephritis, 524 

-diathermy in, 524 

-radiant light in, 524 

-pelvic inflammatory conditions, 522 

-prostatitis, 523 

-diathermy, 523 

-electric massage, 523 



INDEX 


Physiotherapy, glands, diseases of, and, 
524 

-adenitis, tuberculous, 526 

-heliotherapy, 526 

-cystic goiter, 524 

-ionization in, 524, 525 

-ductless, 526, 527 

-exophthalmic goiter, 526 

-electricity in, 526 

-ionization in, 526 

— gymnastics, medical and orthopedic, 235 

-types of exercises, 235-239 

-active, 235-237 

-definition of, 235 

-assistive, 235 

-definition of, 235 

-passive, 235 

-definition of, 235 

-resistive, 235-237 

-definition of, 235 

-value of, 239 

— heat in, 213 

— hospital practice and, 214 

— hospital requirements for, 216 
-apparatus, 216 

-special, 212, 213 

-floor space, 216 

-personnel, 216 

— hydrotherapy, 211 
-uses of, 216 

— importance of, 214, 215 

— industrial accidents and, 217, 218 

— joints and, 488 

-arthritis deformans, 488, 489 

-bursitis, 490 

-gout, 489 

— massage, 215 

-contra-indications, 224 

-definition of, 215 

-equipment, 219 

-general, 224 

-abdomen and, 226 

-arm and, 224, 225 

-back and, 226, 227 

-chest and, 226 

-leg and, 225 

-regional technic, 224-227 

-general indications, 224 

-history of, 215, 216 

-length of treatment, 219 

-lubricants on hands, 219 

-principles of, 227 

-schools of, 218 

-English, 218 

-Hoflfa, 219 

-Swedish, 218 

-types of movements, 220 

-effleurage, 220, 226 

-effects, 220 

-friction, 223-226 

-indications, 223 

-petrissage, 221-225 

-effects of, 221, 222 

-tapotement, 222, 225 

-various movements in, 222, 223 

— -vibration, 223 


Physiotherapy, massage, types of move¬ 
ments, vibration effe.cts, 223 
medical school curriculum and, 214 

— motor neuron lesions and, 471 

-classification of, 471 

-birth hemiplegia, 471 

-cerebral degeneration, 472 

-cord lesions, 472 

-encephalitis lethargica, 472 

hemiplegia following cerebral hem¬ 
orrhage, 471 

-infantile paralysis, 472, 477 

-exercises in, 472 

-apparatus, 473-475 

-types of, 473-477 

— neuromuscular lesions, 471 

— occupational therapy, 217 

— peripheral nerve lesions and, 477 

-muscle nerve testing in, 477, 478 

-apparatus, 479 

-chart for recording results, 479, 

480 

-electrical diagnosis at operation, 

480 

-importance of, 480 

-faradic current, 477, 478 

-galvanic current, 477, 478 

-preliminary preparation of pa¬ 
tient, 479 

-technic, 479 

-myositis, 483 

-acute, 483 

-chronic, 483 

-traumatic acute, 483 

-neuralgia, 482 

-neurasthenia, 483 

-electricity in, 483 

-ultraviolet light in, 483 

-neuritis, 482 

-acute, 482 

-brachial, 482 

-chronic, 482 

-sciatic, 483 

-neuroma, 482 

-tenosynovitis, 484 

-torn muscle insertions, 484 

-treatment of, 481 

-electricity, 481 

-heat, 481 

-massage, 481 

-Volkmann’s contracture, 482 

— physical education, 231 
-importance of, 231 

— post-war reconstruction and, 217 

— postural defects and, 529 

-diagnosis of, 532, 533 

-general indications, 529, 535 

-head and shoulders, 530 

-exercises, 530, 531 

-importance of correction, 529 

-kyphosis, 530 

-exercises, 530, 531 

-lordosis, 531 

-exercises, 532 

-scoliosis, 534 

-exercises, 534, 535 



828 


INDEX 


Physiotherapy, postural defects and, 
scoliosis types, 532 

— radiant light in, 213 

— references, 539-542 

— respiratory diseases and, 501 
-bronchitis, 504 

-bronchopneumonia, 504 

-coryza, 501, 502 

-empyema, 511 

-diathermy, 511 

-radiant light, 511 

-ultraviolet light, 511 

-laryngitis, 503 

-gas, 503 

-tuberculous, 503 

-pleural adhesions, 511, 512 

-pleuritis, 511 

-diathermy, 511 

-pneumonia, lobar, 504 

-diathermy, 505 

— -clinical results, 507 

-effect, 506 

-results in various types, 505, 

506 

-technic, 505 

-types of, 505 

-sinusitis, 504 

-tonsillitis, 502 

-tuberculosis, pulmonary, 507 

-exercises, 508, 509 

-hydrotherapy, 510 

-massage, 510 

-ultraviolet light, 508-510 

-technic of application, 509, 510 

— scars and, 524 

-diathermy, 528 

-galvanism, 528 

-radiant light, 528 

— skin diseases and, 513 
-acne, 513 

-ultraviolet light, 513 

-x-ray, 513 

-alopecia, 512, 513 

-alopecia areata, 513 

-angioma, 513 

-electrolysis, 513, 514 

-radium, 514 

-boils, 514 

-burns, 514 

-first degree, 514 

-skin grafting, 514 

-ultraviolet light, 514 

-carbuncle, 514 

-diathermy, 514 

-callosities, 515 

-eczema, 516 

-ultraviolet light, 516 

-epithelioma, 516 

-radium and x-ray, 516 

-erysipelas, 516 

-ultraviolet light, 517 

-erythema induratum, 517 

-leukoderma, 517 

-lupus, 517 

-nevi, 517 

-pruritus, 518 


Physiotherapy, skin diseases and, pru¬ 
ritus, radium, 518 

-ultraviolet light, 518 

-x-ray, 518 

-pruritus ani, 518 

-electricity, 518 

-iodin ionization, 518 

-x-ray, 518 

-pruritus senilis, 518 

-electricity, 518 

-x-ray, 518 

-psoriasis, 517 

-radium in, 512 

-telangiectasis, 519 

-tinea, 518, 519 

-ulcers, 519 

-radiant light, 519 

-ultraviolet light, 519 

-ultraviolet light in, 512 

-x-ray in, 512 

— ultraviolet light in, 213 
-effects of, 213 

— U. S. Army and, 211, 212 
-results of, 212 

— U. S. Navy and, 212 
-results of, 212 

— U. S. Public Health Service and, 212, 
217 

— vocational training, 217 

Pineal body, in organotherapeutics. See 
Organotherapeutics. 

Pituitary body. See Hypophysis. 

Pituitrin, in organotherapeutics, 728, 739 
Pleurisy, hydrotherapy in, 428 

— physiotherapy in, 510, 511 

— thermotherapy in. See Thermotherapv. 
Pleuritis, physiotherapy in, 510, 511 
Pluriglandular organotherapy. See Or¬ 
ganotherapeutics. 

Pneumonia, hydrotherapy in, 444 

— lobar, 504 

-diathermy in, 504-507 

— thermotherapy in. See Thermotherapy. 

— x-ray therapy in,” 630 
Podagra, hydrotherapy in, 431 
Poisoning. See Poisons. 

Poisons, absorption of, 156 

-paths of, 156, 157 

-modifications, 157 

— administration, methods of, 156, 157 

— alteration in body, 159 

— classification of, 155 

-chemical, 155 

-physiological, 155 

— deposition in body, 159 

— effects of, 155 

-conditions modifying, 155 

— elimination by body, 159 

— factors modifying, 157 
-habit, 158 

-idiosyncrasy, 157 

-tolerance, 158 

— fate of, 159 

— form of, 156 

-effect on action, 156 

— poisoning, 162 



INDEX 


Poisons, poisoning, autopsy in, 166, 167 

-chemical analysis, i66 

-chronic, 161 

-diagnosis, 161 

-diagnosis of, 161 

-differential, 161 

-by chemical analysis, 162 

-diuretics in, 164 

-sodium chlorid, 164 

-water, 164 

-first aid in, 166 

-antidotes, 166 

-references, 167 

-symptomatology of, 159 

-aural disturbances, 161 

-Cheyne-Stokes’ respiration, 160 

-cerebral symptoms, 160 

-cutaneous lesions, 161 

-dyspnea, 160 

-hyperesthesia, 161 

--—motor disturbances, 160 

-nausea, 160 

-neuritis, 161 

-ocular disturbances, 161 

-— pulse changes, 160 

-purging, 160 

-temperature changes, 160 

-vasomotor disturbances, 160 

-vomiting, 160 

-treatment, methods of, 162 

-antidotes, 164, 165 

— -action, 164, 165 

-kinds, 164 

— -removal of poison, 162 

-by emetics, 163 

-by lavage, 163 

-contra-indications to, 163 

— -venesection, 165 

-—-symptomatic, 165, 166 

— references, 167 

— relation to organism, 157 

-factors modifying, 157 

-age, 157 

--disease, 158, 159 

Posterior lobe. See Hypophysis. 
Postural defects, physiotherapy in. See 
Physiotherapy. 

Pregnancy, effects of pancreatectomy on, 
693, 694 

Priessnitz pack, in acute bronchitis, 428 
Prostate, hypertrophy of,^577 
-radium therapy in, 577 

— organotherapeutics. See Organothera- 
peutics. 

-x-ray therapy in, 622, 623 

Prostatitis, physiotherapy in, 523 
Protein, coagulants of, 37 

— liquid, 37 

— precipitants of, 37 

— standard rations of. See Nutrition and 
Dietetics. 

Protein requirement. See Nutrition and 
Dietetics. 

Proteins. See Nutrition and Dietetics. 
Protoplasm, adsorptive powers of, 27 
-factors influencing, 27, 28 


829 

Protoplasm, colloidal constitution of, 60 
Pruritus, physiotherapy in, 518 

— radium therapy in, 570 

— x-ray therapy in, 612, 613 
Psoriasis, physiotherapy in, 517 

— x-ray therapy in, 606, 607 
Pulmonary tuberculosis. See Tubercu¬ 
losis. 

Purins. See Nutrition and Dietetics. 
Pyorrhea, physiotherapy in, 498 

Quartz lamp, 335 

Quartz rays. See Ultraviolet rays. 
Quinsy, thermotherapy in. See Thermo¬ 
therapy. 

Radiant light. See Phototherapy; Physio¬ 
therapy ; T hermotherapy. 
Radiodermatitis. See X-ray therapy. 
Radiotherapeutics. See Radiotherapy. 
Radiotherapy. See Radium therapy; X- 
ray therapy. 

Radium. See Radium therapy. 

Radium burns, 545, 546 
Radium therapy, 543 

— abdominal conditions and, 576 

— application of, 561 

-details of, 564-568 

-general rules, 563, 564 

-methods of, 561-563 

-protection of patient, 564 

— arteriosclerosis and, 560 

— arthritis and, 556 

-chronic, 556 

-gonorrheal, 557 

— arthritis deformans and, 556 

— brain tumor and, 571 

— breast, diseases of, and, 575 
-carcinoma, 575, 576 

— chest, pathological conditions of, and, 
575 

— contra-indications to, 560, 580 

— cross-fire, 564 

— deep therapy, 566 
-technic of, 566-568 

— development of, 543, 544 

— diabetes mellitus and, 560 

— ear, diseases of, and, 573 

— emanation, 551 

-loss of strength, 551 

-physiological action of, 555 

-use of, 551 

— external use of, 568 

— eye, diseases of, and, 571 

— — carcinoma of eyelid, 571 

-opacities of cornea and lens, 571, 57-» 

— gout and, 557, 558 

— Hodgkin’s disease and, 574 

— indications for, 560 

— internal use of, 560 

— joints, tuberculosis of, and, 557 

— leukemia and, 558-560 

— lymphoma and, 574 

— mouth, diseases of, and, 573 

— nose, diseases of, and, 573 

— neuralgia and, 560 




830 


INDEX 


Radium therapy, pelvic diseases and, 577- 
581 

-artificial menopause, 581 

-bladder diseases, 577 

-menorrhagia, 580 

-metrorrhagia, 580 

-prostate, 577 

-rectum, 577 

-testicle, 577 

■-uterus, 578 

-— benign tumor of, 580 

-- — carcinoma of, 578 

-results of treatment, 578-580 

-vagina, 578 

-vulva, 578 

— pneumonia, croupous, and, 560 

— radio-active substances, 544, 550 
-application of, 550 

-external use of, 561, 568 

— radium, 551 

-action of, 551, 552 

-effects, 551, 552 

-general, 551, 552 

-lobal, 551, 552 

-application of, 550, 551 

-care in handling, 545 

-comparison with x-ray, 552, 553 

-dermatology and, 543 

-devices for handling, 546-549 

-discovery of, 544 

-emanations of, 551 

-loss of strength, 551 

-physiological action, 555, 556 

-injuries incidental to handling, 545- 

547 

-methods of avoiding, 549, 550 

-symptoms of, 545-547 

-changes in blood, 548 

-general, 548 

-objective changes, 550 

-subjective disturbances, 547 

-systemic, 550 

-life of, 551 

-medicinal use of, 554 

-methods of administration, 554, 

555 

-mesothorium, 543 

-properties of, 544 

-Radium A. B. C., 551 

-rays, 544, 545 

-alpha, 545 

-beta, 545 

-gamma, 545 

-screening, 545 

-salts of, 544 

-thorium, 543 

-transformation of, 544 

— rays employed, 545 

-alpha, 545 

-beta, 545 

-gamma, 545 

— rheumatism, acute articular, and, 556 

— skin diseases and, 568 

-angiomata, 570, 571 

-angioneurotic edema, 570 

-contractures, 570 


Radium therapy, skin diseases and, epi¬ 
dermoid carcinomata, 569 

-epitheliomata, 569 

-keloids, 570 

-keratoses, 569 

-lichen planus, 570 

-lupus erythematosus, 570 

-lupus vulgaris, 570, 571 

-nevi, 570, 572 

-papillomata, 569 

-pruritus, 570 

-rodent ulcer, 568 

-roentgen ray lesions, 569 

-verrudse, 569 

— skin lesions, superficial, 565 

— summary, 581, 582 

— surgical use of, 561 

— syphilis and, 560 

— therapeutic effects of, 556 

— throat, diseases of, and, 573 

— thymus gland and, 575 

— value of, 581 

Reaction of degeneration, 295 
Rectum, adenocarcinoma of, radium 
therapy in, 577 

Rehabilitation therapy. See Occupational 

therapy, 268 

Renal diseases, balneology in. See Bal¬ 
neology. 

Reproductive organs, effect of x-ray ther¬ 
apy on, 593 

Respiratory diseases, balneology in. See 
Balneology. 

— climatic treatment of, 205 

— hydrotherapy in, 427 

— physiotherapy in. See Physiotherapy. 
Rheumatism, acute articular, 451 

-hydrotherapy in, 451 

-radium therapy in, 556 

— balneology in. See Balneology. 

— chronic, 431 

-hydrotherapy in, 431 

-radium therapy in, 556 

— muscular, 432 

-hydrotherapy in, 432 

— thyroid organotherapy in, 669 
Rheumatoid diseases, climatic treatment 

of, 205 

Rickets, physiotherapy in, 486 
Rodent ulcer. See Uicer. 

Roentgenotherapy. See X-ray therapy. 
Roentgen ray. See X-ray. 

Roentgen ray lesions, radium therapy in, 
569 

Roentgen therapy. See X-ray therapy. 
Rosacea, x-ray therapy in, 605 
Rose cold, x-ray therapy in, 630 

Saline solution. See Solutions. 
Salpingitis, thermotherapy in. See Ther¬ 
motherapy. 

Salts. See Nutrition and Dietetics. 
Sarcoma, x-ray therapy in, 620, 621 
Scars, physiotherapy in. See Physiother¬ 
apy. 

Schnee bath. See Electrotherapy. 



INDEX 


831 


Scoliosis, physiotherapy in, 532 
Secretin, in organotherapy. See Organo- 
therapeutics, 772-774 
Secretion, mechanism of, 52 

— secreting system, 49 

— selective, 52 

Septic infection, thermotherapy in. See 
Thermotherapy. 

Sequardotherapy. See Organotherapy. 
Shock, blood transfusion in, 48 

— saline solutions in, 48 
Shott-Nauheim exercises, in functional 

heart disturbances, 497 
Sigmoid impaction, physiotherapy in, 
500 

Sinus tracts, x-ray therapy in, 630 
Sinusitis, physiotherapy in, 504 

— thermotherapy in. See lliermotlierapy. 

— x-ray therapy in, 629, 630 
Sinusoidal current. See Electrotherapy. 
Skin, diseases of, climatic treatment of, 

206 

— physiotherapy in, 512 

— radium in. See Physiotherapy; Radium 
therapy. 

— thyroid organotherapy in, 668 

— ultraviolet light in. See Physiotherapy. 

— x-ray in. See Physiotherapy. 

Sodium chlorid, absorption by intestinal 

tract, 51 

-mechanism of, 51 

Solutions, 48 

— isotonic, 58 
-definition of, 58 

— saline, 48 

-in hemorrhage, 48 

-in shock, 48 

— standard. See Pharmacology. 

Spas. See Balneology. 

Spleen, in organotherapy. See Organo- 
therapeutics. 

— x-ray therapy in, 592 
Splenectomy. See Organotherapeutics, 

769 

Sprains, thermotherapy in. See Thermo¬ 
therapy. 

Starvation. See Nutrition and Dietetics. 
Static Electricity. See Electrotherapy. 
Stomach, atonic conditions of, thermo- 
therapv in. See Thermotherapy. 

— diseases of, hydrotherapy in, 437, 438 

— phvsiotherapv in, 498 
Subinvolution * of uterus, thermotherapy 

in. See Thermotherapy. 

Sunlight, therapeutic use of. See Photo- 
therapv. 

Suppurative conditions, thermotherapy 
in. See Thermotherapy. 

Suprarenals. See Organotherapeutics. 
Surface tension films, differentiated 
from osmotic membrane, 60 
Surgical tuberculosis. See Tuberculosis. 
Sycosis. See Fungus infections. 

Sycosis vulgaris, x-ray therapy in, 616, 
617 

Syphilis, hydrotherapy in, 439 


Telangiectasis, physiotherapv in, 519 
Tendosynovitis. See Tenosynovitis. 
Tendovaginitis. See Tenosynovitis. 
Tenosynovitis, physiotherapy in, 484 
Tesla current. See Electrotherapy. 

Testes, in organotherapy. See Organo¬ 
therapeutics. 

Tetany. See Organotherapeutics, 675-684 
Testicle, sarcoma of, 577 
-radium therapy in, 577 

— x-rays, effect of, on, 593 
Thermal springs in U. S., 456 
Thermic fever, O’Dwyer treatment in, 453 
Thermopenetration. See Diathermy. 
Thermotherapy, 348 

— abscess and, 384 

— acne, indurated and, 389 
-x-ray in, 389 

— amenorrhea and, 396 

— apparatus, 361 

-applicators, 365 

-autocondensation, 376 

-body oven, 395 

-d’Arsonval current, 371-373 

-deflector, 368 

-dry-hot-air, 368 

-types of, 368-370 

— -electrodes for special applications, 

375 

-high frequency current, 371 

-types, 372-375 

-hydrotherapeutic, 370, 371 

-incandescent light baths, 364, 365 

-lamps, types of, 362 

-Finsen, 362 

-incandescent, 363, 364 

-marine searchlight, 363 

-mercury vapor, 362, 363 

-quartz carbon arc, 361, 362 

-modern types of, 373-375 

-reflector, 366-368 

-- — types of, 366, 367 

-ultraviolet ray, 361 

-whirlpool bath, 371, 372, 382 

-effects, 382 

-equipment, 381 

-in Army, 382, 383 

— appendicitis, catarrhal and, 393 

— Bier’s hyperemia, 357, 359 

— boils and, 384 

— bruises and, 397 

— burns and, 397, 398 

— cholecystitis and, 393 
-contra-indications in, 393 

— conjunctivitis, prurulent and, 386 

— coryza and, 386 

— d’Arsonval current in, 352, 353 
-direct or bipolar, 353 

— desiccation. See Endothermy. 

— diathermy, 391 

_non-infective local conditions and, 

397, 398 

-osteomyelitis and, 403 

-pelvic conditions and, 395 

-pneumonia and, 391, 392 

-results of treatment, 392 







832 


INDEX 


Thermotherapy, dysmenorrhea and, 396 

-diathermy, 396 

-static wave, 396 

— endarteritis obliterans and, 398 

— endothermy, 398 

-apparatus, 398, 333 

-epithelioma, and, 399 

-hemorrhoids, and, 400 

-keratoses, and, 363 

-phlebitis, and, 400 

-technic of, 399 

-tonsils and, 400 

-varicose ulcers and, 401 

— epithelioma and, 398 
-endothermy, 399, 400 

— erysipelas and, 387 

— erythemomelalgia and, 398 

— felons and, 385 

— Finsen light, 362 

— fractures and, 397 

— fungus infection and, 390 
-scalp, 390 

-skin, 390 

-types of, 390 

-favus, 390 

-sycosis, 390 

-tineatonsurans, 390 

— gangrene and, 398 

— gonorrheal arthritis and, 396 
-high-frequency current, 396 

— heat, 348, 349 

-applications of, 377, 378 

-technic, 377, 378 

-forms of, 350 

-conductive, 350 

-effects, 350 

-convective, 348, 350, 356 

-effect, 350 

-conversive, 356 

-action, 356, 357 

-induction, 352 

-methods of application, 351 

-penetration, 351, 352 

-production, 351 

-local effects of, 355 

-local stimulation by, 355 

-physiological effects of, 354-356 

-production by electrical currents, 352, 

353, 354 

-d’Arsonval current, 352, 353 

-reflex effects of, 355, 356 

-therapeutics of, 383, 384 

-thermic effects of, 356 

— hepatitis, acute and, 393 

— history of, 348, 349 

— hives and, 390 

— hydrotherapy and, 381 

-technic of administration, 381-383 

-wet-pack, 381 

-preparation of patient, 381 

— hypoehlorhydria and. 394 
-diathermy, 394 

— hyperemia and, 360 

-advantages of, 360. 361 

-effects of, 357-359 

--—increase of nutrition, 357 


Thermotherapy, hyperemia and, effects 
of, metabolic, 358 

-on infection, 358 

-acute, 358 

-subacute, 358 

— light, 349 

— liver, cirrhosis of, and, 393 
-results of treatment, 393, 394 

— local infection and, 383, 384 

— local septic infection and, 387 
-results of treatment, 388, 389 

— mastoiditis and, 385, 386 

— metabolism, impaired, and, 401 

-forms of heat indicated, 401 

-results of treatment, 401 

— myocarditis and, 398 

— nephritis and, 394 

-acute parenchymatous, 394 

-chronic, 394 

— neuritis and, 397 

— osteomyelitis and, 403 
-ultraviolet ray in, 403 

— otitis media and, 385 

— ■— acute, 385 

-chronic purulent, 385 

— ovaritis and, 397 
—oven bath, 378 

-effects of, 378, 379 

-local hot air bath, 381 

-preparation of patient, 378 

-technic of, 378-381 

-temperature of, 378 

-treatment following, 380 

— pelvic conditions and, 395 

— postoperative conditions and, 402 

— pulmonary conditions and, 390 
-acute pleurisy, 390 

-bronchitis, 390, 391 

-pneumonia, 391 

-results in, 391, 392 

-tuberculosis, 390 

— quinsy and, 384, 385 

— radiant heat, 348 

— radiant light, 377 
-applicators, 378 

-comparative effects with x-ray, 402, 

403 

-extent of exposure, 377 

-length of exposure, 377 

-light baths, 378 

-position of patient, 377 

-postoperative conditions and, 402 

— references, 403, 404 

— salpingitis and, 397 

— septic infection, local, and, 387 
-case reports, 388 

— sinusitis and, 386 

— sprains and, 397 

— stomach, atonic conditions of, and, 394 

— suppurative conditions and, 386 

— technic of, 376 

-general principles, 376 

-methods of, 377 

-skin toleration, 377 

— ultraviolet ray, 403 
-osteomyelitis and, 403 




INDEX 


833 


Thermotherapy, ultraviolet ray, x-ray 
dermatitis and, 403 

— uremic conditions and, 395 

— urticaria and, 390 

— uterine hemorrhage and, 396 

■— uterus, subinvolution of, and, 396 

— vesiculitis, specific, and, 395, 396 
•—whirlpool bath, 371, 372, 382 

--treatment of wounds and, 382 

— whitlows and, 385 

— x-ray, 372 

-apparatus, 372 

-d’Arsonval type, 372 

-comparative effects with radiant 

light, 402, 403 

-dermatitis, 403 

-ultraviolet ray in, 403 

Thorium. See Radium. 

Throat, diseases of, radium therapy in, 
573 

Thymectomy. See Organotherapeutics, 
766 

Thymus, in organotherapy. See Organo¬ 
therapeutics. 

— radium therapy in, 575 

— x-ray therapy, effect on, 592 
Thyroid. See Organotherarpeutics. 

— x-ray therapy in, 592 
Thyroidectomy, effects of, 661, 662 
Thyrotoxicosis. See Goiter, exophthalmic. 
Thyrotoxin, in thyroid gland, 651, 652 
Tinea, physiotherapy in, 518, 519 
Tinea tonsurans. See Fungus infections. 
4 onsillitis, physiotherapy in, 502 

J onsils, diseases of, x-ray therapy in, 
• 623-625 

Toxemia, hydrotherapy in. See Hydro¬ 
therapy. 

Toxic concentration and intoxication, 56 
Toxic substances, concentration of, 56 
-effect of, 56 

— in kidney cells, 56 

-removal of, 56 

Toxicology. See Poisons, 154 
Transthermy. See Diathermy. 
Iuberculosis, pulmonary, climatic treat¬ 
ment of, 201-204 

-heliotherapy in, 345 

-hydrotherapy in, 440, 510 

-physiotherapy in, 507-510 

-thermotherapy in, 390 

-x-ray therapy in, 629 

— surgical, 196 

Typhoid fever, Brand hath in. See Hydro¬ 
therapy. 

— full bath in. See Hydrotherapy. 

— hydrotherapy in, 442 

Ulcer, duodenal, 499 
-physiotherapy in, 499 

— gastric, 499 

-physiotherapy in, 499 

— physiotherapy in, 519 

— rodent, 568 

-radium therapy in, 568 

— varicose, 519 


Ulcer, varicose, ultraviolet light in, 
519 

Ultraviolet light in pulmonary tubercu¬ 
losis, 508-510 

— skin diseases,. 512 

Ultraviolet ray. See Heliotherapy, 329; 

Phototherapy; Thermotherapy. 
Uniglandular organotherapy. See Organo¬ 
therapeutics. 

Uremic conditions, thermotherapy in. 
See Thermotherapy. 

Urinary secretory system, division of, 
53 

-blood, 53 

-secreting membrane, 53 

-urine, 53 

Urine, chlorids in, 53 

— composition of, 53 

— dissolved substances in, 53 

-distribution of, 53 

-factors influencing, 53, 54 

— sulphates in, 53 

— urea in, 53 

Urticaria, thermotherapy in. See Thermo- 
therapy. 

Uterine hemorrhage. See Hemorrhage. 
Uterus, benign tumors of, 580 
-radium therapy in, 580 

— carcinoma of, 578 

-radium therapy in, 578-580 

— infantile, 521 

-physiotherapy in, 521 

Vagina, cancer of, radium therapy in, 578 
Varicose ulcer. See Ulcer. 

Vesiculitis, specific, thermotherapy in. 

See Thermotherapy. 

Visceroptosis, physiotherapy in, 499 
Vitamin diet. See Nutrition and Diet. 
Vitamins. See Nutrition and Dietetics. 
Vocational training. See Occupational 
therapy. 

Vulva, carcinoma of, radium therapy in, 
578 

Water, absorption by body, 44-46 

— as diuretic, 39 

— content in body, 41 

-pathological, 41 

-physiological, 41 

— free, 11, 46, 47 
-definition of, 11 

— hydration, 11 
-definition of, 11 

— in intoxication, 56 

— retention of, 43 

-causes of, 43 

-effects of, 43 

— secretion of by body, 46 

— solvent properties of, 11 
-importance of, 11 

— See also Balneology; Hydrotherapy; 
Nutrition and Dietetics. 

Water therapy, 50. See also Hydrother¬ 
apy. 

Whirlpool bath. See Thermotherapy. 



834 


INDEX 


Whitlows, thermotherapy in. See Ther¬ 
motherapy. 

Whooping cough, x-ray therapy in, 631 

X-ray. See X-ray therapy. 

X-ray burns, physiotherapy in, 514 
X-ray dermatitis, ultraviolet ray in. See 
Thermotherapy. 

X-ray therapy, 583 

— acne and, 615, 616 
-types of, 616 

— acne keloid and, 613 

— actinomycosis and, 612 

— adenitis, tuberculous and, 628, 629 

— amperage, 586, 587 

— apparatus, 584 
-filter, 587 

-transformer, 584, 585 

-tube, types of, 585 

-Coolidge, 585 

-gas, 585 

— asthma and, 630 

— Banti’s disease and, 628 

— basic principles of, 583, 584 

— beta ray, 594 

-effect on bacteria, 594 

— blastomycosis and, 612 

— bromidrosis and, 607 

— carcinoma and, 618-620 

— carcinoma dose, 590 

— castration dose, 593 

— circulatory system and, 590 
-blood, 590 

— danger to various organs, 623 

— depth dose, 593 

— dermatitis papillaris capillitii and, 613 

— dermatology and, 604 

-forms of treatment, 604 

-fractional, 604, 605 

-intensive, 604 

--—semi-intensive, 604 

— development of, 583 

— dosage, 590, 593 

-filtered radiation, 601-604 

-aluminum filter, 602 

-method of computing, 602-604 

-method of computing, 598 

-skin unit, 600 

-unfiltered radiation, 598 

-method of computing, 599-601 

-formulae, 599-601 

— drugs, action of and, 597, 598 
-keratolytic, 597 

— eczema and, 607, 608 

— effect on tissues, 590 

— epithelioma and, 614 

-prickle-cell, 614, 615 

-squamous-cell, 614, 615 

— eyes and, 591 

— favus and, 610-612 

— fibroids, uterine, and, 621, 622 

— fibromata of breast and, 622 

— field of usefulness, 632 

— filter, 587 

— filtered radiation, 618 

— gastro-intestinal tract and, 592 


X-ray therapy, gastro-intestinal tract 
and, intestine, 592 

-salivary glands, 592 

-stomach, 592 

— general considerations, 588-590 

— hay-fever and, 630 

— Hodgkin’s disease and, 626, 627 

— hyperidrosis and, 617 

— hyperthyroidism and, 625, 626 

— hypertrichosis and, 618 

— keloid and, 613 

— kidneys and, 591 

— larynx and, 592 

— leukemia and, 627, 628 

— lichen planus and, 605 

— lungs and, 591 

— lupus erythematosus and, 608 

— lupus vulgaris and, 608 

— malaria and, 631 

— mastitis, chronic, and, 622 

— mastoiditis and, 629, 630 

— melanoma and, 615 

— menorrhagia and, 622 

— mycosis fungoides and, 608, 609 

— nervous system and, 591 

— neuritis and, 630, 631 

— osteomyelitis, tuberculous, and, 629 

— peritonitis, tuberculous, and, 629 

— pertussis and, 631 

— physics of, 584 

— pneumonia and, 630 

— prostatic hypertrophy and, 622, 
623 

— pruritus and, 612 

— pruritus ani and, 612, 613 

— psoriasis and, 606 
-varieties of, 606, 607 

— pulmonary tuberculosis and, 629 

— radiodermatitis, 594 

-degrees of, 594 

-idiosyncrasy, 597 

-sequel* of, 595 

-treatment of, 596 

— reproductive organs, effect on, 593 
-aspermia, 593 

-castration dose, 593 

, — rosacea and, 605 

— sarcoma and, 620, 621 

— sinus tracts and, 630 
* — sinusitis and, 629 

— skin and, 590 

— skin unit, 599, 600 
-definition of, 600 

— spark gap, 586 

— spleen and, 592 

— summary, 631, 632 

— sycosis vulgaris and, 616, 617 

— technic of, 587, 588 

-standardization of, 588 

-variations of, 588 

— thymus and, 592 

— thyroid and, 592 

— tinea tonsurans and, 610, 611 

— tissue response to, 589 

— tonsils and, 623 
-dangers to, 623 



INDEX 


X-ray therapy, tonsils and, dangers to, 
hair, 624 

-parotid gland, 623 

-pituitary gland, 624 

-skin, 624 

-— submaxillary gland, 623 

-thyroid, 623 

— unfiltered radiation, 605 


X-ray therapy, voltage, 586 

— whooping-cough and, 631 

— x-ray, 583 

-definition of, 584 

-discovery of, 583 

-importance of, 583 

Zootherapy. See Organotherapy. 
































































































































































































































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